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COLLEGE  OF 

PHYSICIANS  AND  SURGEONS 

LIBRARY 


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MINOR  SURGERY 


AND 


BANDAGING 


INCLUDING 


THE  TREATMENT  OF  FRACTURES  AND  DISLOCATIONS,  THE 

LIGATION  OF  ARTERIES,  AMPUTATIONS,  EXCISIONS  AND 

RESECTIONS,  INTESTINAL  ANASTOMOSIS,  OPERATIONS 

UPON  NERVES  AND  TENDONS,  TRACHEOTOMY, 

INTUBATION  OF  THE  LARYNX,  ETC. 


BY 

HENRY   R.  WHARTON,  M.D., 

PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  WOMAN'S    MEDICAL  COLLEGE  OF    PENN- 
SYLVANIA,  SURGEON    TO    THE    PRESBYTERIAN    HOSPITAL,   AND    THE    CHIL- 
DREN'S   HOSPITAL;    CONSULTING   SURGEON  TO  ST.  CHRISTOPHER'S 
HOSPITAL,   AND    THE    BRYN    MAWB    HOSPITAL;    FELLOW 
OF  THE  AMERICAN  SURGICAL  ASSOCIATION. 

FIFTH  EDITION,  ENLARGED  AND  THOROUGHLY  REVISED, 
WITH  509  ILLUSTRATIONS. 


LEA   BROTHERS  &  CO., 
PHILADELPHIA  AND  NEW  YORK 

1902. 


Entered  according  to  Act  of  Congress,  in  the  year  1902,  by 

LEA   BROTHERS   &   CO., 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


TVPlll 


WESTCOTT    &.    THOMSON,  WILLIAM    J.     DORNAN, 

ELECTROTYPERS,    PHILADA.  PRINTER,    PHILADA 


PREFACE  TO  THE  FIFTH  EDITION. 


The  author  has  endeavored  to  present  a  concise  descrip- 
tion of  the  various  bandages,  surgical  dressings,  and 
minor  surgical  procedures  employed  in  the  practice  of 
surgery  at  the  present  time.  The  preparation  and  appli- 
cation of  aseptic  and  antiseptic  dressings  have  also 
received  full  consideration,  and  the  importance  of  Sur- 
gical Bacteriology  is  recognized  in  a  special  chapter. 
The  article  on  Bandages  is  fully  illustrated  with  cuts, 
chieflv  photographic,  which  furnish  an  accurate  and  clear 
representation  of  the  most  important  bandages  used  in 
surgical  practice.  The  same  is  in  a  measure  true  of  the 
section  upon  Fractures  and  Dislocations,  which  is  like- 
wise photographically  illustrated. 

The  work  also  contains  short  articles  on  Tracheotomy, 
Intubation  of  the  Larynx,  Ligation  of  Arteries,  and 
Amputations.  Though  these  subjects  are  scarcely  to  be 
included  in  the  term  "  Minor  Surgery,"  it  is  believed  that 
they  will  render  the  volume  more  serviceable  to  the 
student.  In  view  of  the  great  attention  now  paid  in  our 
medical  schools  to  operative  procedures  on  the  cadaver 
and  the  importance  of  this  method  of  instruction,  a  sec- 


4  PREFACE  TO   THE  FIFTH  EDITION. 

tion  on  this    subject  was  added  to    the  Fourth  Edition 
and  is  continued  in  the  present  revision. 

The  author  feels  that  he  would  be  remiss  if  he  omitted 
an  acknowledgment  of  the  favor  so  widely  manifested 
toward  this  work.  A  call  for  five  editions  is  no  idle 
compliment,  nor  has  it  been  construed  as  relieving  the 
author  from  the  duty  of  keeping  the  book  thoroughly 
revised  to  the  date  of  each  issue.  Surgery  progresses, 
and  those  books  are  fortunate  which  meet  with  a  degree 
of  favor  enabling  their  authors  by  frequent  revision  to 
keep  them  abreast  of  its  continuous  advances. 

The  author  desires  to  express  his  thanks  to  Dr.  J.  H. 
Jopson  for  assistance  in  revising  the  proof-sheets. 

1725  Spruce  St.,  Philadelphia, 
May,  1902. 


CONTENTS, 


PAKT  I. 

BANDAGING. 


PAGES 

Varieties  of  Bandages 23-41 

Bandages  for  the  Head  and  Neck 41-53 

Bandages  of  the  Upper  Neck 54-69 

Bandages  of  the  Trunk 69-73 

Bandages  of  the  Lower  Extremity 73-84 

Special  Bandages 84-93 

Fixed  Dressings  or  Hardening  Bandages 93-109 


PART  II. 

MINOR  SURGERY. 

Surgical  Bacteriology      111-123 

Theory  of  Asepsis  and  Antisepsis  in  Wound  Treatment  .    .    .  123-128 

Agents  Employed  to  Secure  Asepsis 128-137 

Preparation   of  Materials  Used  in   Aseptic    Operations  and 

Dressings 137-14o 

Preparation  of  Gauze  Dressings 145-149 

Methods   and   Dressings    Employed   in    the    Treatment    of 

Wounds  to  Secure  Asepsis 149-150 

Preparation  for  Aseptic  Operation  and  Dressing  of  Wounds  .  150-166 

Materials  Used  in  Surgical  Dressings 166-1/1 

Procedures  Employed  in  Minor  Surgery 171-232 

Anaesthetics 232-25o 

Trusses 255-259 

5 


6  CONTENTS. 

PAGES 

Catheters  and  Bougies 259-268 

Sutures • •  268-280 

Methods  of  Intestinal  Anastomosis 280  286 

Ligatures  Used  in  the  Treatment  of  Vascular  Growths    .    .    -  286-291 

Treatment  of  Hemorrhage •    •    ■  291~^U 

Opening  and  Dressing  of  Abscesses ■    •    •  311-315 

shock : 315-318 

Dressing  of  Wounds,  Burns  and  Scalds,  Bed-sores,  Sprains  .    .  318-331 


PART  III. 


FRACTURES. 

General  Consideration  of  Fractures 333-34o 

Separation  of  Epiphyses • 2^404 

Treatment  of  Special  Fractures _.-...  d48-4U4 

Compound  and  Ununited  Fractures      • 404-410 


PART  IV. 


DISLOCATIONS. 

General  Consideration  of  Dislocations tll'tl'l 

n      .-,-..,      ,.  413-443 

Special  Dislocations • 


PART  V. 

OPERATIONS. 

445_447 
Ligation  of  Arteries    .    ._ 

Ligation  of  Special  Arteries 

PART  VI. 

AMPUTATIONS, 

477-490 

General  Consideration  of  Amputations 

„-.',.  ..  490-531 

Special  Amputations ■    ■ 


CONTEXTS.  7 

PART  VII. 

EXCISIONS  AND   RESECTIONS,    AND   SPECIAL 
OPERATIONS. 

PAGES 

General  Consideration  of  Excisions  and  Resections 533-636 

Special  Excisions  and  Resections •  536-553 

Trephining 553-558 

Laminectomy 558-559 

Operations  upon  Nerves 559-564 

Operations  upon  Tendons 564-570 

Removal  of  the  Breast 570 

Tracheotomy 570 

Laryngotomy 577 

Laryngo-tracheotomy 578 

Intubation  of  the  Larynx 578-584 

Operations  updn  the  Kidney .  584—585 

Operations  upon  the  Colon 585-587 

Removnl  of  Appendix  Vermiformis 587-588 

Lithotomy 588-590 

Circumcision 590-591 

Removal  of  the  Testicle 591 

Operation  for  Varicocele 591 

Cholecystotomy 591 

(Esophagotomy 592 

Gastrostomy •    • 592-596 

Pyloroplasty 596 

Pylorectomy  and  Gastro-duodenostomy 597-598 

Gastroenterostomy 599 

Osteotomy 599-601 


Index 603 


PAET  I. 

BANDAGING. 


Bandages. — These  constitute  one  of  the  most  widely 
used  and  important  surgical  dressings  ;  they  are  employed 
to  hold  dressings  in  contact  with  the  surface  of  the  body, 
to  make  pressure,  to  hold  splints  in  place  in  the  treatment 
of  fractures  and  dislocations,  and  to  maintain  in  their 
natural  position  parts  which  may  have  become  displaced. 

Bandages  may  be  prepared  of  various  materials,  such 
as  linen,  crinoline,  flannel,  cheese-cloth  or  tobacco-cloth, 
rubber-sheeting,  or  muslin,  bleached  or  unbleached ;  the 
latter  material  is  the  most  commonly  employed,  by  reason 
of  its  cheapness ;  flannel,  from  its  elasticity,  is  sometimes 
used,  but  its  employment  for  bandages  is  now  generally 
limited  to  its  use  in  dressings  for  operative  work  in  con- 
nection with  the  eye  and  abdomen,  and  for  a  primary 
roller  in  the  application  of  plaster-of- Paris  dressings. 

Bandages  are  either  simple,  when  composed  of  one  piece 
of  material,  such  as  the  ordinary  roller-bandage,  or  com- 
pound, when  prepared  of  one  or  more  pieces  adapted  by 
size  and  shape  to  particular  objects. 

The  importance  of  being  familiar  with  the  general 
rules  of  bandaging  and  proficient  in  the  application  of 
the  roller-bandage  cannot  be  overestimated,  and  both  the 
student  and  the  general  practitioner  will  never  have  cause 
to  regret  the  time  occupied  in  learning  to  apply  neatly 
this  form  of  surgical  dressing. 

2  17 


18 


BANDAGING. 


A  well-applied  bandage  adds  to  the  security  of  the  dress- 
ing and  the  comfort  of  the  patient,  and  the  method  of 
application  often  secures  for  the  physician  the  confidence 
both  of  the  patient  and  of  his  friends ;  while,  on  the 
other  hand,  a  badly  applied  bandage  is  apt  to  be  uncom- 
fortable and  insecure,  and  to  meet  with  their  adverse 
criticism. 

The  Roller-bandage. — The  roller-bandage  consists  of 
a  strip  of  woven  material,  prepared  from  some  one  of  the 
materials  previously  mentioned,  of  variable  length  and 
width  according  to  the  portion  of  the  body  to  which  it  is 

Fig.  1. 


Bandage-winder. 

to  be  applied ;  this,  for  ease  of  application,  is  rolled  into 
a  cylindrical  form. 

The  material  commonly  employed  for  the  roller-band- 
age is  unbleached  muslin,  although,  for  special  purposes, 
linen,  flannel,  rubber-sheeting,  crinoline,  or  cheese-cloth 
may  be  used.  It  is  important  that  the  roller-bandage 
should  consist  of  one  piece,  free  from  seams  and  selvage, 
for  if  made  of  a  number  of  pieces  sewed  together,  or  if  it 
contains  creases  or  selvage,  it  cannot  be  so  neatly  applied, 
and  it  is  not  so  comfortable  to  the  patient,  as  it  is  apt  to 
leave  creases  upon  the  skin. 


THE  ROLLER-BANDAGE. 


19 


In  preparing  the  ordinary  muslin  bandage,  the  material 
is  torn  in  strips  varying  in  length  and  width  aceording  to 
the  part  of  the  body  to  which  it  is  to  be  applied,  and  it  is 
then  rolled  into  a  cylinder,  either  by  the  hand  or  by  a 
machine  constructed  for  the  purpose  (Fig.  1). 

It  is  important  that  every  student  and  practitioner 
should  be  able  to  roll  a  bandage  by  hand,  for  in  practice 
the  medical  attendant  may  at  any  moment  be  called  upon 
to  prepare  a  bandage,  in  order  to  apply  a  dressing,  and  the 
art  of  preparing  a  bandage  is  easily  acquired  by  a  little 

Fig.  2. 


Rolling  a  bandage  by  hand. 

practice.  To  roll  a  bandage  by  hand,  the  strip  of  muslin 
should  be  folded  at  one  extremity  several  times  until  a 
small  cylinder  is  formed ;  this  is  then  grasped  by  its  ex- 
tremities by  the  thumb  and  index  finger  of  the  left  hand ; 
the  free  extremity  of  the  strip  is  then  grasped  between 
the  thumb  and  index  finger  of  the  right  hand,  and  by 
alternate  pronation  and  supination  of  the  right  hand  the 
cylinder  is  revolved  and  the  roller  is  formed ;  the  firm- 
ness of  the  roller  will  depend  upon  the  amount  of  tension 
which  is  kept  upon  the  free  extremity  of  the  strip  during 
the  revolution  of  the  cylinder  (Fig.  2).     A  bandage  rolled 


20 


BANDAGING. 


in  the  form  of  a  cylinder  is  called  a  single  or  single-headed 
roller  (Fig.  3) ;  if  rolled  from  each  extremity  toward  the 
centre,  so  that  two  cylinders  are  formed  joined  by  the 


Fig.  3. 


Fig.  4. 


Single  roller. 


Double  roller. 


central  portion  of  the  strip,  the  double  or  double-headed 
roller  is  formed  (Fig.  4). 

Double  rollers  are  not  much  used,  and  in  practice  the 
single  roller  will  be  found  to  be  amply  sufficient  for  the 
application  of  almost  all  the  bandages  employed  in  sur- 
gical dressings. 

The  free  end  of  the  roller-bandage  is  called  the  initial 
extremity ;  the  end  which  is  enclosed  in  the  centre  of  the 
cylinder  is  its  terminal  extremity  ;  and  the  portion  between 
the  extremities  the  body ;  a  roller  has  also  two  surfaces, 
external  and  internal. 

Dimensions  of  Bandages. — Bandages  vary  in  length 
and  width  according  to  the  purposes  for  which  they  are 
employed,  and  in  practice  it  will  be  found  that  a  small 
variety  of  bandages  will  be  amply  sufficient  for  the  appli- 
cation of  the  ordinary  surgical  dressings. 

The  following  list,  comprising  those  most  frequently 
used,  will  show  their  dimensions  : 

Bandages  one  inch  wide,  three  yards  in  length,  for  band- 
ages for  the  hand,  fingers,  and  toes. 


GENERAL  RULES  FOR  BANDAGIM;.  21 

Bandages  two  inches  wide,  six  yards  in  length,  for  head- 
bandages  and  for  the  extremities  in  children. 

Bandages  two  and  a  half  inches  wide,  seven  yards  in 
length,  for  bandages  of  the  extremities  in  adults;  a  roller 
of  this  size  is  the  one  most  generally  used. 

Bandages  three  inches  wide,  nine  yards  in  length,  for 
bandages  of  the  thigh,  groin,  and  trunk. 

Bandages  four  inches  wide,  ten  yards  in  length,  for 
bandages  of  the  trunk. 

General  Rules  for  Bandaging. — In  applying  a  roller- 
bandage,  the  operator  should  place  the  external  surface  of 
the  free  extremity  of  the  roller  upon  the  part,  holding  it 
in  position  with  the  fingers  of  the  left  hand  until  fixed  by 
a  few  turns  of  the  roller,  the  cylinder  being  held  in  the 
right  hand  by  the  thumb  and  fingers ;  for  thus  as  the 
bandage  is  unwound  it  rolls  into  the  operator's  hand, 
thereby  giving  him  more  control  of  it ;  care  should  also 
be  taken  that  the  turns  are  applied  smoothly  to  the  surface, 
and  that  the  pressure  exerted  by  each  turn  is  uniform. 

AVhen  a  bandage  is  applied  to  a  limb,  the  surgeon  should 
see  that  the  part  is  in  the  position  it  is  to  occupy  as  re- 
gards flexion  and  extension  when  the  dressing  is  com- 
pleted, for  a  bandage  applied  wThen  the  limb  is  flexed  will 
exert  too  much  pressure  when  the  limb  is  extended,  and 
then  may,  by  the  pressure  it  exerts,  become  a  matter  of 
discomfort  or  even  of  danger  to  the  patient,  or  if  applied 
to  an  extended  limb  it  will  become  uncomfortable  upon 
flexion. 

My  experience  has  been  that,  as  a  rule,  those  who  have 
had  little  experience  with  the  application  of  the  roller- 
bandage  are  apt  to  apply  the  bandages  too  tightly,  and 
this  may  lead  to  disastrous  consequences,  gangrene  of  the 
extremities  having  resulted  from  the  too  tight  application 
of  bandages,  especially  in  the  dressing  of  fractures.  Pro- 
fessor Ash  hurst,  in  his  clinical  teaching,  advised  students 
to  make  use  of  a  larger  number  of  turns  of  a  bandage  in 
securing  fracture-dressings  rather  than  to  depend  upon  a 
few  turns  too  firmly  applied — advice  which  certainly  con- 
duces to  the  safety  and  comfort  of  the  patient.     When  the 


22 


BANDAGING. 


bandage  has  been  completed,  the  terminal  extremity  should 
be  secured  by  a  pin  or  safety-pin  applied  transversely 
to  the  bandage,  and  if  a  pin  be  used  its  point  should  be 


Fig.  5. 


Method  of  removing  a  bandage. 


buried  in  the  folds  of  the  bandage ;  if  the  bandage  be  a 
narrow  one,  the  end  may  be  split  and  the  two  tails  result- 
ing secured  around  the  part  by  tying. 


Fig.  6. 


Bandage-scissors. 


Removal  of  Bandages. — In  removing  a  bandage,  the 
folds  should  be  carefully  gathered  up  in  a  loose  mass  as 


VARIETIES  OE  BANDAGES.  '2:\ 

the  bandage  is  unwound,  the  mass  being  transferred  rapidly 
from  one  hand  to  the  other,  thus  facilitating  its  removal 
and  preventing  the  part  from  becoming  entangled  in  its 
loops  (Fig.  5).  If  it  is  desirable  to  cut  the  bandage  to 
remove  it,  the  use  of  scissors  made  for  this  purpose  will 
be  found  most  satisfactory  (Fig.  6). 


VARIETIES  OF  BANDAGES. 

Circular  Bandage. — This  bandage  consists  of  a  few 
circular  turns  around  a  part,  each  turn  covering  accurately 
the  preceding  turn.  This  variety  of  bandage  may  be  used 
to  retain  a  dressing  to  a  limited  portion  of  the  head,  neck, 
or  limbs,  to  make  compression  upon  the  veins  of  the  arm 
before  performing  venesection,  or  to  secure  a  compress  to 
control  venous  hemorrhage  (Fig.  11,  b). 

Oblique  Bandage. — In  this  form  of  bandage  the  turns 
are  carried  obliquely  over  the  part,  leaving  uncovered 
spaces  between  the  successive  turns  (Fig.  7).     It  cannot 

Fig.  7. 


Oblique  bandage. 


be  applied  with  much  firmness  on  account  of  the  uncov- 
ered portions  of  skin  between  the  turns  of  the  bandage, 
and  its  principal  use  is  for  the  application  of  temporary 
dressings,  such  as  wet  dressings  which  may  require  fre- 
quent removal. 

Spiral  Bandage. — In  this  bandage  the  turns  are  carried 
around  the  part  in  a  spiral  direction,  each  turn  overlap- 
ping a  portion  of  the  preceding  one,  usually  one-third  or 
one-half;  it  may  be  applied  as. an  ascending  spiral  (Fig.  8) 


^4  BANDAGING. 

or  as  a  descending  spiral  (Fig.  9).  This  bandage  may 
be  used  to  cover  a  part  which  does  not  increase  rapidly  in 
diameter ;  for  instance,  the  abdomen,  chest,  or  arm. 

Fig.  8. 


Ascending  spiral  bandage. 
Fig.  9. 


Descending  spiral  bandage. 

Spiral  Reversed  Bandage. — This  bandage  is  a  spiral 
bandage,  but  differs  from  the  ordinary  spiral  bandage  in 
having  its  turns  folded  back  or  reversed  as  it  ascends  a 
part  the  diameter  of  which  gradually  increases.  By  its 
use,  it  is  possible  to  cover  by  spiral  turns  a  part  conical  in 
shape,  so  as  to  make  equable  pressure  upon  all  parts  of 
the  surface.  The  reverses  are  made  as  follows :  After 
fixing  the  initial  extremity  of  the  roller,  as  the  part  in- 
creases in  diameter  the  bandage  is  carried  off  a  little 
obliquely  to  the  axis  of  the  limb  for  from  four  to  six 
inches  ;  the  index  finger  or  thumb  of  the  disengaged  hand 
is  placed  upon  the  body  of  the  bandage  to  keep  it  securely 
in  place  upon  the  limb,  the  hand  holding  the  roller  is 
carried  a  little  toward  the  limb  to  slacken  the  unwound  por- 
tion of  the  bandage,  and  by  changing  the  position  of  the 
hand  holding  the  bandage  from  extreme  supination  to 
pronation  the  reverse  is  made  (Fig.  10).     Care  should  be 


VARIETIES  OF  BANDAGES. 


25 


taken  not  to  attempt  to  make  the  reverse  while  the  band- 
age is  tense,  for  by  so  doing  the  bandage  is  twisted  into 
a  cord  which  is  unsightly  and  uncomfortable  to  the  patient, 
instead  of  forming  a  closely  fitting  reverse. 

The  reverse  should  be  completed  before  the  bandage  is 
carried  around  the  limb,  and  when  it  has  been  completed 
it  may  be  slightly  tightened  so  as  to  conform  to  the  part 
accurately. 

Fig.  10. 


Method  of  making  reverses. 

The  reverses  should  be  in  line  to  have  the  bandage  pre- 
sent a  good  appearance,  and  care  should  be  taken  that  the 
reverses  should  not  be  made  over  prominent  bony  parts 
of  the  limb,  for  if  they  occupy  such  positions  they  cause 
creases  in  the  skin  and  become  uncomfortable  to  the 
patient. 

To  make  reverses  neatly  and  to  have  them  in  line, 
require  skill  and  practice ;  a  well-applied  spiral  reversed 
bandage  is  a  test  of  a  competent  bandager. 

Spica-bandage. — When  the  turns  of  the  roller  cross 
each  other  in  the  form  of  the  Greek  letter  lambda,  leaving 
the  previous  turn  about  one-third  uncovered,  the  bandage 
is  known  as  a  spica-bandage  (Fig.  11,  a).     These  spica- 


26 


BANDAGING. 


bandages  are  especially  serviceable  as  a  means  of  retaining 
surgical  dressings  upon  particular  portions  of  the  surface 
of  the  body,  such  as  the  shoulder,  groin,  or  foot. 


Fig.  11. 


*i  ... 


Spica-bandage. 


Circular  bandage. 


Figure -of- eight  Bandage. — This  bandage  receives  its 
name  from  the  turns  being  applied  so  as  to  form  a  figure- 
of-eight.  This  method  of  application  is  made  use  of  in 
the  Barton's  bandage,  the  bandages  of  the  knee  and  elbow, 
and  many  other  bandages. 


Fig.  12. 


Recurrent  bandage. 


Recurrent  Bandage. — This  bandage  derives  its  name 
from  the  fact  that  the  roller  after  covering  a  certain  part 
of  the  surface  is  reflected  and  brought  back  to  the  point 
of  starting ;   it  is  then  reversed  and  carried  toward  the 


( 'O MPO UND  BANDAGES. 


27 


opposite  point,  and  this  manipulation  is  continued  until 
the  part  is  covered  by  these  recurrent  turns,  which  are 
then  secured  by  a  few  circular  turns  (Fig.  12).  This  is 
the  bandage  usually  employed  in  the  dressing  of  stump- 
after  amputation. 


Compound  Bandages. 

These  bandages  are  usually  formed  of  several  pieces  of 
muslin  or  other  material,  sewed  or  pinned  together,  and 
are  employed  to  fulfil  some  special  indication  in  the  appli- 
cation of  dressings  to  particular  parts  of  the  body.  The 
most  useful  of  the  compound  bandages  are  the  T-bandages 
and  the  many -tailed  bandages. 

T-bandage. — The  single  T-bandage  consists  of  a  hori- 
zontal band  to  which  is  attached,  about  its  middle,  another 
having  a  vertical  direction  ;  the  horizontal  piece  should  be 
about  twice  the  length  of  the  vertical  piece  (Fig.  13).     The 


Fig.  13 


Fig.  14. 


Single  T-bandage. 


Single  T-bandage  for  chest. 


single  T-banda^e  may  be  used  to  retain  dressings  to  the 
head,  the  horizontal  piece  being  passed  around  the  head 
from  the  occiput  to  the  forehead,  the  vertical  piece  being 
passed  over  the  head  and  secured  to  the  horizontal  piece, 
the  shape  and  width  of  the  two  pieces  being  varied  accord- 
ing to  the  indications.     In  applying  dressings  to  the  anal 


28 


BANDAGING. 


region  or  perineum,  or  in  securing  a  catheter  in  a  perineal 
wound,  the  single  T-bandage  will  he  found  most  useful. 
In  applying  a  T-bandage  for  this  purpose,  the  body  of  the 
bandage  is  placed  over  the  spine,  just  above  the  pelvis,  and 
the  horizontal  portion  is  tied  around  the  abdomen.  The 
free  extremity  is  split  into  two  tails  for  about  two-thirds 
of  its  length,  and  is  carried  over  the  anal  region  and 
brought  up  between  the  thighs,  the  terminal  strips  passing 
one  on  each  side  of  the  scrotum  and  being  secured  to  the 
horizontal  strip  in  front.     The  single  T-bandage  may  be 

Fig.  15. 


T-bandage  of  groin. 

variously  modified  according  to  the  indications  which  are 
to  be  met;  for  instance,  in  applying  a  dressing  to  the 
breasts  the  horizontal  strip  passing  around  the  chest  may 
be  made  ten  or  twelve  inches  in  width ;  the  vertical 
strip,  two  inches  in  width,  passes  from  the  back  over  the 
shoulder  and  is  secured  to  the  horizontal  strip  in  front 
(Fig.  14).     For  the  groin,t  a  piece  of  muslin  six  inches 


COMPO  UXD  BA  XI)  A  GES. 


29 


wide  at  its  base  and  thirty  inches  long  is  sewed  to  a  hori- 
zontal strip  of  muslin  one  and  a  half  yards  long  and  two 
inches  in  width.  It  may  be  applied  as  in  Fig.  15  to  hold 
a  dressing  to  this  part. 

Double  T-bandage. — The  double  T-bandage  differs 
from  the  single  bandage  in  having  two  vertical  strips 
attached  to  the  horizontal  strip,  and  it  may  be  used  for 
much  the  same  purposes  as  the  single  T-bandage  (Fig.  16). 

Fig.  16. 


Double  T-bandage. 

It  may  be  conveniently  used  for  retaining  dressings  to  the 
chest,  breast,  or  abdomen ;  when  used  for  this  purpose  the 
horizontal  portion  should  be  from  eight  to  twelve  inches 
wide  and  long  enough  to  pass  one  and  a  quarter  times 
about  the  chest ;  two  vertical  strips,  two  inches  wide  and 
twenty  inches  long,  should  be  attached  to  the  horizontal 
strip  a  short  distance  apart  near  its  middle.  In  applying 
this  bandage  to  the  chest,  the  horizontal  strip  is  placed 
around  the  chest  so  that  the  vertical  strips  occupy  a  posi- 
tion on  either  side  of  the  spine ;  the  overlapping  end  of 
the  horizontal  portion  is  secured  by  pins  or  safety-pins, 
and  the  vertical  strips  are  next  carried  one  over  either 
shoulder  and  secured  to  the  other  portion  of  the  bandage 
in  front  of  the  chest  (Fig.  17). 

The  double  T-bandage  may  also  be  used  to  secure  dress- 


30 


BANDAGING. 


ings  to  the  nose,  in  which  event  the  strips  should  be  quite 
narrow,  about  one  inch  in  width,  and  should  be  applied  as 
shown  in  Fig.  18. 


Fig.  17. 


Fig.  18. 


Double  T-bandage  of  chest. 


Double  T-bandage  of  nose. 


Many-tailed  Bandages  or  Slings. — These  bandages 
are  prepared  from  pieces  of  muslin  of  various  lengths  and 
breadths,  which  are  split  at  each  extremity  into  two,  three, 
or  more  tails  up  to  within  a  few  inches  of  their  centres, 
their  width  and  length  being  regulated  by  the  part  of  the 
body  to  which  they  are  to  be  applied. 

The  four-tailed  bandage  may  be  found  useful  as  a  tem- 
porary dressing  in  cases  of  fracture  of  the  jaw,  or  to  hold 
dressings  to  the  chin.  It  may  be  prepared  by  taking  a 
portion  of  a  roller-bandage  three  inches  wide  and  one 
yard  in  length,  and  splitting  each  extremity  up  to  within 
two  inches  of  the  centre ;  it  is  then  applied  as  seen  in 
Fig.  19. 

The  four-tailed  bandage  may  also  be  used  to  retain  dress- 
ings to  the  scalp,  and  may  be  prepared  by  taking  a  piece  of 
muslin  one  yard  and  a  quarter  long  and  six  or  eight  inches 
in  width,  splitting  it  at  each  extremity  into  two  tails  within 
six  inches  of  the  centre ;  it  may  then  be  applied  as  seen 
in  Fig.  20. 

The  four-tailed  bandage  may  also  be  used  in  the  tern- 


COMPOUND  BANDAGES. 


31 


porary  dressing  of  fractures  of  the  clavicle,  the  body  of 
the  bandage  being  placed  upon  the  elbow  of  the  injured 


Fig.  19. 


Four-tailed  bandage  of  chin. 


Fig.  20. 


Four-tailed  bandage  of  head. 


side,  two  tails  passing  around  the  body,  fixing  the  arm  to 
the  side,  and  two  tails  passing  over  the  sound  shoulder. 


Fig.  21. 


4 


Many-tailed  bandage  of  abdomen. 


Many-tailed  Bandage  of  Abdomen. — This  bandage  may 
also  be  used  for  holding  dressings  in  contact  with  the  abdo- 
men or  trunk,  and  is  the  bandage  which  most  surgeons 


32 


BANDAGING. 


employ  to  hold  the  dressings  to  a  laparotomy  wound,  and 
to  give  support  to  the  abdominal  walls  after  this  operation. 
In  preparing  this  bandage,  a  strip  of  muslin  or  flannel, 
one  and  a  half  yards  in  length  and  eighteen  to  twenty 
inches  in  width,  is  required ;  the  extremities  may  be  split 
so  as  to  form  a  four-  or  six-tailed  bandage.  In  applying 
this  bandage  to  the  abdomen,  the  body  is  placed  upon  the 
patient's  back  and  the  tails  are  brought  around  the  abdo- 
men and  overlap  each  other,  and  when  sufficiently  firmly 
drawn  to  make  the  desired  amount  of  pressure  they  are 
secured  by  means  of  safety-pins  (Fig.  21). 


Handkerchief-bandages. 

The  use  of  handkerchiefs  or  square  pieces  of  muslin 
for  the  temporary  or  permanent  dressing  of  wounds,  fract- 
ures, or  dislocations  was  advocated  many  years  ago  by  M. 
Mayor,  a  Swiss  surgeon,  who  wrote  an  extensive  work 


Fig.  22. 

\ 

I    i    1 

.ijj 

.iiii 

Jiliii 

'iiii1 
i| 

^=sFii!= 

Ik                     lii!                        L'l 
.!      \             is     ^==z^         fJ 

jl; \jj!_.Z -   1 

iijj 

i=i=;:   ■ 

imi 

--2^=?-  *-===•'  - 

Fig.  23. 


The  square. 


The  oblong. 


upon  this  subject,  in  which  he  reduced  their  application  to 
a  system.  He  employed  a  handkerchief  or  a  square  piece 
of  muslin,  and  by  various  modifications  in  the  application 
of  these  developed  a  number  of  very  ingenious  bandages. 
The  various  forms  which  the  handkerchief  or  square 
(Fig.  22)  is  made  to  assume  are  as  follows  :     The  oblong, 


HA  ND  KER  CHIEF-  IlAShMi  /•>. 


33 


made  by  folding  the  square  once  or  twice  on  itself  (Fig. 
23).  The  triangle,  made  by  bringing  together  the  diag- 
onal angles  of  the  square  (Fig.  24).  The  line  of  the  fold- 
ing is  known  as  the  base,  the  angle  opposite  the  base  the 
apex,  and  the  other  angles  the  extremities. 


Fig.  24. 


The  triangle. 


The  cravat  is  prepared  from  the  triangle  by  bringing  the 
apex  to  its  base,  and  folding  it  a  number  of  times  upon 
itself  until  the  desired  width  is  obtained  (Fig.  25). 


Fig.  25. 


The  cravat. 


The  cord  is  formed  from  the  cravat  twisted  upon  itself 
(Fig.  26).  The  names  of  the  various  handkerchief-band- 
ages are  derived  from  the  shape  of  the  handkerchiefs 
used  and  the  parts  to  which  they  are  applied ;  the  names 


Fig.  26. 


The  cord. 


serve  as  guides  in  their  application.  It  is  to  be  remem- 
bered that  the  base  of  the  triangle  or  the  body  of  the  cravat 
is  to  be  placed  upon  the  portion,  the  designation  of  which 
forms  the  first  portion  of  the  name  of  the  bandage ;  thus, 
3 


34 


BAND  A  GING. 


in  the  occipitofrontal  triangle,  the  shape  of  the  handker- 
chief is  given,  and  we  know  that  the  base  of  the  triangle 
is  to  be  applied  to  the  occiput  and  the  apex  carried  to  the 
forehead.  In  using  the  cravats  the  same  rule  applies ; 
thus,  in  the  bis-axillary  cravat  the  body  of  the  cravat  is 
to  be  placed  in  the  axilla  of  the  affected  side,  the  extremi- 
ties crossed  over  the  corresponding  shoulder  and  carried 
over  the  chest,  one  before,  the  other  behind,  to  the  axilla 
of  the  opposite  side,  where  they  are  secured. 

Fig.  27. 


V 


Occipitofrontal  triangle. 

The  Occipito-frontal  Triangle. — To  apply  this  hand- 
kerchief, place  the  base  of  the  triangle  upon  or  a  little 
below  the  occiput,  and  bring  the  apex  forward  over  the 
head,  allowing  it  to  drop  over  the  forehead ;  next  bring 
the  extremities  of  the  handkerchief  forward  and  tie  them 
in  a  knot  over  the  forehead  ;  finally  turn  up  the  apex  over 
the  knotted  ends  and  pin  it  to  the  body  of  the  handker- 
chief (Fig.  27). 


HANDKERCHIEF-BANDA  GES. 


35 


The  Mento-vertico-occipital  Cravat. — To  apply  this 

handkerchief,  the  middle  of  the  base  of  the  cravat  is  placed 
under  the  chin  ;  the  extremities  are  then  carried  in  front 
of  the  ear  on  each  side  to  the  vertex  of  the  skull,  and  are 
crossed  at  that  point ;  the  ends  are  then  carried  downward 
over  the  parietal  region  to  the  occiput,  and  are  secured  by 
a  knot  at  this  point  (Fig.  28).  Another  method  of  apply- 
ing this  handkerchief  consists  in  placing  the  base  of  the 


Fig.  28. 


Fig.  29. 


Mento-vertico-occipital  cravat. 


Mento-vertico-occipital  cravat  (modified). 


cravat  under  the  chin  and  carrying  the  extremities  over 
the  vertex  of  the  skull,  crossing  them  at  that  point ;  then 
carrying  them  downward  to  the  occiput,  and  crossing  them 
again  here  and  passing  them  forward  around  the  chin,  and 
finally  securing  the  ends  by  a  knot  (Fig.  29).  The  turns 
of  the  latter  handkerchief  correspond  exactly  to  the  turns 
of  the  Barton's  bandage  of  the  head. 


36 


BANDAGING. 


These  handkerchief-bandages  may  be  used  to  secure 
dressings  to  the  chin  or  scalp,  or  may  be  employed  as  tem- 
porary dressings  to  secure  fixation  of  the  parts  in  cases  of 
fracture  or  dislocation  of  the  jaw. 

The  Bis-axillary  Cravat. — To  apply  this  handker- 
chief, the  body  of  the  cravat  is  placed  in  the  axilla,  and 


Fig.  30. 


Bis-axillary  cravat. 

the  ends  are  brought  up,  one  in  front  of,  the  other  behind, 
the  axilla,  and  are  made  to  cross  over  the  top  of  the 
shoulder ;  the  extremities  are  then  carried  across  the  back 
and  chest  respectively  to  the  opposite  axilla,  where  they 
are  secured  by  tying  (Fig.  30).  This  handkerchief  may 
be  employed  to  secure  dressings  in  the  axilla,  or  to  hold 
dressings  in  contact  with  the  shoulder. 


HANDKERCHIEF-BANDA  GES. 


37 


The  Dorso-axillary  Cravat.— This  handkerchief  is 
applied  by  placing  the  body  of  the  cravat  over  the  spine 
between  the  scapulas,  and  then  carrying  one  extremity  over 
the  shoulder  and  through  the  axilla  backward  to  meet  the 
other  extremity,  which  has  been  carried  through  the  axilla 
and  over  the  other  shoulder  to  the  back,  where  the  ends 
are  secured  by  a  knot  (Fig.  31).     This  handkerchief  may 

Fig.  31. 


Dorso-axillarv  cravat. 


be  used  to  hold  dressings  to  the  axilla  or  upper  portion  of 
the  back  of  the  chest. 

The  Compound  Dorso-bis-axillary  Cravat. — To  ap- 
ply this  handkerchief,  two  cravats  are  required.  The  base 
of  one  cravat  is  placed  over  the  front  of  one  shoulder,  and 
the  ends  are  passed,  one  over  the  top  of  the  shoulder,  the 
other  through  the  axilla,  and  they  are  then  secured  by  a 
single  knot  over  the  scapula  ;  the  ends  are  next  secured  by 
tying  them  in  a  loop.  The  second  cravat  is  next  placed 
in  front  of  the  shoulder  on  the  opposite  side,  and  the  ends 


38  BANDAGING. 

are  respectively  carried  over  the  shoulder  and  through  the 
axilla  to  the  back,  where  they  are  secured  by  a  single  knot ; 
the  ends  of  the  handkerchief  are  then  passed  through  the 
loop  of  the  first  handkerchief  and  secured  by  a  knot 
(Fig.  32).     This  handkerchief  may  be  used  to  draw  the 

Fig.  32. 


Compound  dorso-bis-axillary  cravat. 

shoulders  backward  in  cases  of  dislocation  or  fracture  of 
the  clavicle. 

Triangular  Cap  or  Suspensory  of  the  Breast. — To 
apply  this  handkerchief,  the  base  of  the  triangle  is  placed 
under  the  aifected  breast,  and  one  extremity  is  carried  be- 
neath the  axilla  of  the  same  side,  and  the  other  extremity 
is  carried  around  the  opposite  side  of  the  neck,  and  they 
are  secured  together  upon  the  back  by  a  knot ;  the  apex 
should  then  be  brought  up  over  the  breast  and  shoulder 
of  the  affected  side,  and  pinned  to  the  bandage  over  the 
scapula  (Fig.  33).  This  handkerchief  may  be  employed 
to  sling  the  breast  in  nursing-women,  or  to  hold  a  dressing 
to  the  breast. 


HAXDKEBCHIEF-BANDA  GES.  39 

Fig.  33. 


/  i  / 


Triangular  cap  or  suspensory  of  the  breast. 


The  Gluteo-femoral  Triangle.— In  applying  this  hand- 
kerchief, a  cravat  is  first  fastened  around  the  waist,  and  a 
second  handkerchief  folded  into  a  triangle  has  its  base 
placed  in  the  gluteo-femoral  fold,  and  its  extremities  car- 
ried around  the  thigh  and  secured  in  front  by  a  knot; 
the  apex  of  the  handkerchief  is  then  carried  upward  and 
passed  beneath  the  cravat  around  the  waist,  and  is  turned 
down  and  pinned  to  the  body  of  the  triangle  (Fig.  34). 
This  handkerchief  may  be  used  to  retain  dressings  to  the 
region  of  the  buttock  or  hip;  by  unpinning  the  apex  and 
turning  it  downward,  ready  access  can  be  had  to  the  parts 

beneath. 

Gluteo-inguinal  Cravat.— In  applying  this  handker- 
chief, the  base  of  the  cravat  is  placed  just  over  the  gluteo- 
femoral  fold,  and  the  extremities  are  carried  forward,  one 


40  BANDAGING. 

around  the  inner,  the  other  around  the  outer  portion  of 
the  thigh,  and  they  are  made  to  cross  in  the  groin  ;  the 
ends  are  next  passed  around  the  pelvis  and  secured  to- 
gether upon  the  back  by  a  knot  (Fig.  35).     This  handker- 

Fig.  34. 


Gluteo-femoral  triangle. 

chief  may  be  employed  to  hold  dressings  to  the  region  of 
the  groin. 

By  employing  two  cravats,  a  double  gluteo-inguinal 
cravat  may  be  applied,  which  may  be  used  to  hold  dress- 
ings to  both  groins.  The  turns  of  these  cravats  corre- 
spond to  the  turns  of  the  single  and  double  spica-band- 
ages  of  the  groin. 

I  have  described  a  few  of  the  many  ingenious  bandages 
devised  by  Mayor  to  substitute  the  use  of  the  roller- 
bandage,  which  will  give  the  student  some  idea  of  their 
design  and  application.  It  is  well  to  bear  in  mind  this 
system  of  dressing,  for  the  occasion  might  occur  in  which 
the  ordinary  means  of  bandaging  could  not  be  obtained, 
and  the  use  of  handkerchiefs  might  answer  a  useful  pur- 


BANDAGES  OF  THE  HEAD.  41 

pose  as  temporary  dressings.  I  think  their  principal  use 
is  for  temporary  dressings,  and  I  do  not  believe  they  will 
ever  take  the  place  of  the  roller-bandage,  which  can  be 

Fig.  35. 


Gluteo-ineuinal  cravat. 


applied  with  greater  nicety  and  exactness,  and  certainly 
presents  a  much  neater  appearance. 


BANDAGES  OF  THE  HEAD. 

Barton's  Bandage.  Roller  Two  Inches  in  Width,  Six 
Yards  in  Length. — The  initial  extremity  of  the  roller 
should  be  placed  on  the  head  just  behind  the  mastoid 
process,  and  the  bandage  should  then  be  carried  under  the 
occipital  protuberance  obliquely  upward  under  and  in  front 
of  the  parietal  eminence  across  the  vertex  of  the  skull, 
then  downward  over  the  zygomatic  arch,  under  the  chin, 
thence  upward  over  the  opposite  zygomatic  arch  and  over 
the  top  of  the  head,  crossing  the  first  turn  which  was  made, 
as  nearly  as  possible  in  the  median  line  of  the  skull,  and 
carrying  the  turns  of  the  roller  under  the  parietal  eminence 
to  the  point  of  commencement.  The  bandage  is  then 
passed  obliquely  around  under  the  occipital  protuberance 
and  forward  under  the  ear  to  the  front  of  the  chin,  thence 


42 


BANDAGING. 


back  to  the  point  from  which  the  roller  started.  These 
figure-of-eight  turns  over  the  head  and  the  circular  turns 
from  the  occiput  to  the  chin  should  be  repeated,  each  turn 
exactly  overlapping  the  preceding  one  until  the  bandage 
is  exhausted  (Fig.  36).  The  extremity  should  then  be 
secured  by  a  pin  ;  and  pins  should  be  introduced  at  the 
points  where  the  turns  cross  each  other,  to  give  additional 
fixation  to  the  bandage.     In  applying  the  bandage,  care 


Fig.  36. 


Fig.  37. 


Barton's  bandage. 


Barton's  bandage,  showing  crossing  of  turns 
at  vertex. 


should  be  taken  to  see  that  the  turns  overlap  each  other 
exactly,  and  that  the  turns  passing  over  the  vertex  cross 
as  nearly  as  possible  in  the  median  line  of  the  skull 
(Fig.  37). 

Modified  Barton's  Bandage. — To  obtain  additional 
security  in  the  application  of  the  Barton's  bandage,  a  turn 
of  the  bandage  passing  from  the  occiput  to  the  forehead 
may  be  made,  this  turn  being  interposed  between  the  turns 


BANDAGES  OF  THE  HEAD.  43 

of  the  bandage  as  ordinarily  applied  (Fig.  38).  In  ap- 
plying this  bandage,  after  the  first  set  of  turns  has  been 
completed — that  is,  after  the  bandage  has  been  brought 
back  to  the  occiput — the  bandage  is  carried  forward  upon 
the  head  just  over  the  ear,  around  the  forehead  and  back- 
ward above  the  ear  on  the  opposite  side  to  the  occiput ; 
this  being  done,  the  ordinary  figure-of-eight  and  circular 

Fig.  38. 


Modified  Barton's  bandage. 

turns  are  made,  and  when  these  have  been  completed 
another  occipi to-frontal  turn  may  be  made  as  described 
above,  and  this  may  be  repeated  as  often  as  is  desired 
until  the  bandage  is  exhausted,  when  the  extremity  is  fast- 
ened with  a  pin,  and  pins  are  introduced  also  at  all  points 
at  which  the  turns  cross. 

Use. — This  bandage  is  one  of  the  most  useful  of  the 
bandages  of  the  head,  being  employed  to  secure  fixation 
of  the  jaw  in  cases  of  fracture  or  dislocation,  and  for  the 


/ 


44 


BANDAGING. 


Fig.  39. 


\ 


application  of  dressings  to  the  chin.  I  have  also  employed 
it  in  place  of  the  head-gear  in  slinging  patients  for  the 
application  of  the  plaster-of-Paris  jacket  in  cases  of  dis- 
ease of  the  spine,  a  stout  cord  or  a  piece  of  bandage  about 
three  inches  wide  and  one  yard  long  being  passed  under 
the  turns  crossing  over  the  vertex  ;  this  cord  is  then  se- 
cured to  the  cross-bar  of  the  extension  apparatus  (Fig.  39). 
This  will  be  found  quite  as  comfortable  to  the  patient  as 

the  ordinary  head-gear  employed, 
and  much  less  likely  to  slip  out 
of  place  and  interfere  with  the 
breathing  of  the  patient. 

A  firmly  applied  Barton's 
bandage  holds  the  jaws  so  closely 
together  that  care  should  be  taken 
in  applying  it  to  patients  who  are 
under  the  influence  of  an  anaes- 
thetic, for  if  vomiting  occurs  the 
material  may  not  escape  from 
the  mouth,  and  suffocation  might 
occur  unless  the  bandage  were 
promptly  removed.  This  acci- 
dent I  once  saw  occur,  and  the 
patient's  condition  was  alarming 
until  the  bandage  was  cut,  al- 
lowing the  jaw  to  be  opened  and 
the  contents  of  the  mouth  to  escape. 

Gibson's  Bandage.  Roller  Two  Inches  in  Width,  Six 
Yards  in  Length. — The  initial  extremity  of  the  roller 
should  be  placed  upon  the  vertex  of  the  skull  in  a  line 
with  the  anterior  portion  of  the  ear ;  the  bandage  is  then 
carried  downward  in  front  of  the  ear  to  the  chin,  and 
passed  under  the  chin,  and  is  carried  upward  on  the 
same  line  until  it  reaches  the  point  of  starting.  The 
turns  are  repeated  until  three  complete  turns  have  been 
made ;  the  bandage  is  then  continued  until  it  reaches  a 
point  just  above  the  ear,  when  it  is  reversed  and  is  carried 
backward  around  the  occiput,  and  is  continued  around  the 
head  and  forehead    until  it  reaches  its  point  of  origin  ; 


U 


Barton's     head-bandage,    em- 
ployed  for  suspension.    (Park.) 


BANDAGES  OF  THE  HEAD. 


45 


Fig.  40. 


these  circular  turns  are  applied  until  three  have  been 
made.  When  the  bandage  reaches  the  occiput,  having 
completed  the  third  turn,  it  is  allowed  to  drop  down  to 
the  base  of  the  skull,  and  it  is  then  carried  forward  below 
the  ear  and  around  the  chin,  being  brought  back  upcn  the 
opposite  side  of  the  head  and  neck  to  the  point  of  origin ; 
these  turns  are  repeated  until  three  complete  turns  have 
been  made,  and  upon  the  completion  of  the  third  turn  the 
bandage  is  reversed  and  car- 
ried forward  over  the  occiput 
and  vertex  to  the  forehead, 
and  its  extremity  is  here  se- 
cured with  a  pin.  Pins  should 
also  be  applied  at  the  points 
where  the  turns  of  the  band- 
age cross  each  other  (Fig.  40). 

Use. — This  bandage  mav 
be  used  to  fix  the  lower  jaw 
in  cases  of  fracture  or  dis- 
location of  the  jaw,  but  is 
very  apt  to  change  its  posi- 
tion, and  is,  therefore,  not  so 
satisfactory  as  the  Barton's 
bandage    for    this     purpose. 

Oblique  Bandage  of  the  Angle  of  the  Jaw.  Boiler 
Two  Inches  in  Width,  Sir  Yards  in  Length. — The  initial 
extremity  of  the  roller  is  placed  just  in  front  of  and  above 
the  left  ear,  and  if  the  left  angle  of  the  lower  jaw  is  to  be 
covered  in,  the  bandage  is  then  carried  from  left  to  right, 
making  two  complete  turns  around  the  cranium  from  the 
occiput  to  the  forehead ;  if,  however,  the  right  angle  of 
the  lower  jaw  is  to  be  covered  in,  the  turns  should  be  made 
in  the  opposite  direction.  Having  made  two  turns  from 
the  occiput  to  the  forehead,  the  bandage  is  allowed  to  drop 
down  upon  the  neck,  and  is  carried  forward  under  the  ear 
and  under  the  chin  to  the  angle  of  the  jaw ;  it  is  next 
carried  upward  close  to  the  edge  of  the  orbit,  and  obliquely 
over  the  vertex  of  the  skull,  then  down  behind  the  right 
ear,  continuing  this  oblique  turn  under  the  chin  to  the  left 


Gibson's  bandasre. 


46 


BANDAGING. 


angle  of  the  jaw,  where  it  ascends  in  the  same  direction  as 
the  previous  turn.  Three  or  four  of  these  oblique  turns 
are  made,  each  turn  overlapping  the  preceding  one  and 
passing  from  the  edge  of  the  orbit  toward  the  ear  until 
the  space  is  covered  in ;  the  bandage  is  then  carried  to  a 
point  just  above  the  ear  on  the  opposite  side,  is  reversed, 
and  finished  with  one  or  two  circular  turns  from  the  occi- 
put to  the  forehead,  the  extremity 
being  secured  by  a  pin  (Fig.  41). 
Use. — This  will  be  found  one  of 
the  most  useful  of  the  head-band- 
ages ;  it  may  be  used  with  a  com- 
press in  treating  fractures  of  the 
angle  of  the  lower  jaw,  for  hold- 
ing dressings  to  the  lower  part  of 
the  chin  and  to  the  vault  of  the 
cranium,  and  is  especially  useful 
in  retaining  dressings  to  the  sides 
of  the  face  and  the  parotid  region. 
As  before  stated,  it  may  be  ap- 
plied to  cover  either  the  right  or 
left  side  of  the  face,  and,  by  rea- 
son of  the  oblique  turns,  holds 
its  position  most  securely,  having 
little  tendency  to  become  displaced. 

Recurrent  Bandage  of  the  Head.  Roller  Two  Inches 
in  Width,  Six  Yards  in  Length. — The  initial  extremity  of 
the  roller  is  placed  upon  the  lower  part  of  the  forehead 
and  the  bandage  is  carried  twice  around  the  head  from  the 
forehead  to  the  occiput  to  secure  it,  When  the  bandage 
is  brought  back  to  the  median  line  of  the  forehead  it  is 
reversed,  and  the  reversed  turn  is  held  by  the  finger  of  the 
left  hand  while  the  roller  is  carried  over  the  top  of  the 
head  along  the  sagittal  suture  to  a  point  just^  below  the 
occipital  protuberance  ;  here  it  is  reversed  again,  and  the 
reverse  is  held  by  an  assistant  while  the  roller  is  carried 
back  to  the  forehead  in  an  elliptical  course,  each  turn  cov- 
ering in  two-thirds  of  the  preceding  turn.  These  turns 
are  repeated  with  successive  reverses  at  the  forehead  and 


Oblique  bandage  of  the  angle  of 
the  jaw. 


BANDAGES  OF  THE  HEAD.  47 

occiput  until  one  side  of  the  head  is  completely  covered 
in,  and  when  this  is  accomplished  a  circular  turn  is  made 
from  the  forehead  to  the  occiput  to  hold  the  reverses  in 
place. 

The  opposite  side  of  the  head  is  next  covered  in  by  ellip- 
tical reversed  turns  made  in  the  same  manner,  and  when 
this  has  been  accomplished  two  or  three  circular  turns  are 
carried  around  the  head  from  the  forehead  to  the  occiput, 
to  fix  the  preceding  turns.     Pins  should  be  applied  at  the 

Fig.  42. 


Recurrent  bandage  of  the  head. 

forehead  and  occiput  at  the  points  where  the  reversed  turns 
concentrate  (Fig.  42). 

Use. — This  bandage  when  well  applied  is  one  of  the 
neatest  of  the  head-bandages,  and  it  will  be  found  useful 
to  retain  dressings  to  the  vault  of  the  cranium  in  the  treat- 
ment of  wounds  of  the  scalp  in  this  region.  It  will  also 
be  found  of  service  in  holding  dressings  to  fractures  of  the 
cranium  and  to  wounds  after  the  operation  of  trephining. 
In  restless  patients  it  will  sometimes  become  displaced,  and 
it  may  be  rendered  more  secure  by  pinning  a  strip  of  band- 
age to  the  circular  turn  in  front  of  the  ear  and  carrying 


48 


BANDAGING. 


Fig.  43. 


it  down  under  the  chin  and  up  to  a  corresponding  point 
on  the  opposite  side,  where  it  is  pinned  to  the  circular 
turn ;  or  one  or  two  oblique  turns  passing  from  the  circu- 
lar turn  over  the  vertex  of  the  skull  downward  behind 
the  ear,  under  the  chin  and  up  to  the  circular  turn  in  front 
of  the  ear,  may  be  applied.  The  course  of  these  turns  is 
the  same  as  those  employed  in  the  oblique  bandage  of  the 
angle  of  the  jaw,  the  extremity  being  secured  by  a  pin. 

Transverse  Recurrent  Bandage  of  the  Head.  Roller 
Two  Inches  in  Width,  Six  Yards  in  Length. — The  initial 
extremity  of  the  roller  is  placed  upon  the  lower  part  of  the 
forehead  and  the  bandage  is  carried  twice  around  the  head 

from  the  forehead  to  the  occi- 
put to  secure  it.  The  head  is 
then  covered  in  by  transverse 
turns  of  the  bandage ;  the  first 
turn,  starting  from  a  point  be- 
hind the  ear  on  one  side,  is 
carried  below  the  occiput  to  a 
corresponding  point  behind  the 
opposite  ear,  and  ascending 
transverse  turns  are  then  made 
and  carried  over  the  head,  each 
turn  covering  in  about  two- 
thirds  of  the  preceding  turn, 
until  the  forehead  is  reached, 
and  when  this  has  been  reached 
two  or  three  circular  turns  are 
carried  around  the  head  from  the  forehead  to  the  occiput 
to  fix  the  recurrent  turns.  Pins  should  be  applied  at  the 
points  of  starting  and  finishing  of  the  reversed  turns  be- 
hind the  ears,  and  at  the  occiput  and  forehead  (Fig.  43). 
Use. — This  bandage  may  be  employed  to  secure  dress- 
ings to  the  scalp  in  cases  of  wounds  or  in  injuries  to  the 
skull,  and  is  used  for  the  same  purposes  as  the  recurrent 
bandage  of  the  head. 

V-bandage  of  the  Head.  Roller  Two  Inches  in  Width, 
Four  Yards  in  Length. — The  initial  extremity  of  the  roller 
is  secured  by  two  turns  of  the  bandage  around  the  era- 


Transverse  recurrent  bandage  of 
the  head. 


BANDAGES  OF  THE  HEAD. 


49 


niuni  from  the  forehead  to  tin.'  occiput,  and  when  the 
roller  reaches  the  occipital  protuberance  it  is  allowed  to 
drop  a  little  below  this,  and  is  carried  forward  below 
the  ear  around  the  front  of  the  chin  and  lower  lip,  then 
backward  to  the  point  of  starting.  These  turns  passing 
from  the  occiput  to  the  forehead  and  from  the  occiput  to 
the  chin  are  alternately  made  until  a  sufficient  number 
have  been  applied,  and  the  extremity  is  secured  by  a  pin 
over  the  occiput  (Fig.  44). 

This  bandage  may  be  modified  by  carrying  the  turns 
from  the  occiput  forward  under  the  ear  and  around  the 
upper  lip  and  back  to  the  occiput,  and  alternating  these 
turns  with  the  occipito-frontal  turns ;  if  employed  in  this 
way,  a  bandage  of  one  and  one-half  inches  in  width  should 
be  used. 

Use. — This  bandage  may  be  employed  to  hold  dressings 
to  the  front  of  the  chin,  to  the  upper  and  lower  lips  in 
cases  of  wounds,  or  to  give  support  to  these  parts  after 
plastic  operations. 


Y\a.  44. 


Fig.  45. 


V-bandasre  of  the  head. 


Head-and-neck  bandage. 


Head-and-neck  Bandage.  Roller  Two  Inches  in  Width, 
Four  Yards  In  Length. — The  initial  extremity  of  the  roller 
is  placed  upon  the  forehead  and  carried   backward  just 


50 


BANDAGING. 


above  the  ear  to  the  occiput,  and  is  then  brought  forward 
around  the  opposite  side  of  the  head  to  the  point  of  start- 
ins:.  Two  of  these  circular  turns  are  made  to  fix  the 
bandage,  and  when  it  is  carried  back  to  the  occiput  it  is 
allowed  to  drop  down  slightly  upon  the  neck,  and  is  then 
carried  around  the  neck,  the  turns  around  the  head  alter- 
nating with  the  neck-turns  until  a  sufficient  number  of 
these  have  been  applied,  when  the  extremity  of  the  bandage 
is  secured  by  a  pin  at  the  point  of  crossing  of  the  turns 
at  the  back  of  the  head  (Fig.  45). 

Use. — This  bandage  may  be  found  useful  in  securing 
dressings  to  the  anterior  or  posterior  portion  of  the  neck 
or  to  the  region  of  the  occiput.  Care  should  be  taken  to 
apply  it  in  such  a  manner  that  too  much  pressure  is  not 
made  by  the  turns  around  the  neck,  which  would  be  un- 
comfortable to  the  patient,  and  might  seriously  interfere 
with  respiration. 

Crossed  Bandage  of  One  Eye.  Roller  Two  Inches  in 
Width,  Four  Yards  in  Length. — The  initial  extremity  of 
the  bandage  is  placed  upon  the  forehead  and  fixed  by  two 

circular  turns  passing  around  the 
head  from  the  occiput  to  the  fore- 
head ;  the  roller  is  then  carried 
back  to  the  occiput  and  passed 
around  this  and  brought  forward 
below  the  ear,  and  passing  over 
the  outer  portion  of  the  cheek  is 
carried  upward  to  the  junction  of 
the  nose  with  the  forehead,  and  is 
then  conducted  over  the  parietal 
eminence  downward  to  the  occi- 
put; a  circular  fronto-occipital 
turn  is  next  made,  and  when  the 
bandage  is  brought  back  to  the  oc- 
ciput it  is  brought  forward  again 
to  the  cheek.  It  should  then  ascend  to  the  forehead, 
covering  in  two-thirds  of  the  preceding  turn,  and  again  be 
conducted  back  to  the  occiput ;  these  turns  are  repeated, 
the  oblique  turns  covering  the  eye  alternating  with  circu- 


Fig.  46. 


Crossed  bandage  of  one  eye. 


BANDAGES  OF  THE  HEAD.  51 

lar  turns  around  the  head  until  the  eye  is  completely  en- 
closed (Fig.  46),  and  the  bandage  is  finished  by  making 
a  circular  turn  about  the  head  and  introducing  a  pin  to 
secure  its  extremity.  It  will  be  found  more  comfortable 
to  the  patient  to  include  in  the  turns  of  the  bandage  the 
ear  on  the  same  side  on  which  the  eye  is  covered. 

Use. — This  bandage  will  be  found  useful  in  retaining 
dressings  to  one  eye.  It  will  be  more  comfortable  to  the 
patient  if  a  flannel  roller  be  used  to  apply  this  bandage,  as 
well  as  the  bandage  which  includes  both  eyes. 

Crossed  Bandage  of  Both  Eyes.  Roller  Two  Inches 
in  Width,  Six  Yards  in  Length. — The  initial  extremity  of 
the  roller  is  placed  upon  the  forehead  and  secured  by  two 
circular  turns  of  the  bandage  passing;  around  the  head 
from  the  forehead  to  the  occiput ;  the  roller  is  then  carried 
downward  behind  the  occiput  and  brought  forward  below 
the  ear  to  the  upper  portion  of  the  cheek  ;  it  is  then  car- 
ried upward  to  the  junction  of  the  nose  with  the  forehead 
and  conducted  over  the  parietal  eminence  to  the  occiput ; 
a  circular  turn  is  now  made  around 
the   head  from  the  occiput  to  the  ' 

forehead,  and  the  roller  is  carried 
from  the  occiput  over  the  parietal 
eminence  of  the  opposite  side  for- 
ward to  the  junction  of  the  nose 
with  the  forehead,  then  downward 
over  the  eye  and  outer  portion  of  W 
the  cheek  below  the  ear  and  back  to  £   \^ 

the  occiput ;  a  circular  turn  around  P^jl*^ 

the  head  is  next  made,  and  this  is 
followed  by  a  repetition  of  the  pre- 
vious turns,  ascending  over  one  eye, 
descending  over  the  other  eye,  each 
turn    alternating:    with    a    circular   . 

iii  mi  Crossed  bandage  of  both  eje&- 

turn  around  the  head.    These  turns 

are  repeated  until  both  eyes  are  covered  in,  and  the  band- 
age is  finished  by  making  a  circular  turn  around  the  head, 
the  extremity  being  secured  by  a  pin  (Fig.  47).  In  this 
bandage  both  ears  may  be  covered  in  or  left  uncovered. 


52 


BANDAGING. 


Use. — This  bandage  may  be  used  to  apply  dressings  to 
both  eyes,  and  both  of  these  bandages  covering  the  eyes 
are  used  where  it  is  desired  to  make  pressure;  but  for  the 
simple  application  of  a  light  dressing  or  of  a  bandage  for 
the  exclusion  of  light,  the  Liebreich's  bandage  (Fig.  89) 
will  be  found  more  comfortable  to  the  patient. 

Occipito-facial  Bandage.  Boiler  Two  Inches  in  Width, 
Four  Yards  in  Length. — The  initial  extremity  of  the  roller 
is  placed  upon  the  vertex  of  the  head  and  the  bandage  is 
carried  downward  in  front  of  the  ear,  under  the  jaw,  and 
upward  upon  the  opposite  side  in  the  same  line  to  the  ver- 
tex ;  two  or  three  of  these  turns  are  made,  one  turn  accu- 
rately covering  in  the  other.  A  reverse  should  be  made 
just  above  and  in  front  of  the  ear,  and  two  or  three  turns 
are  then  made  around  the  head  from  the  occiput  to  the 
forehead,  which  completes  the  bandage  (Fig.  48).  Pins 
should  be  inserted  at  the  points  where  the  turns  of  the 
bandage  cross  each  other. 

Use. — This  bandage  is  employed  to  secure  dressings  to 
the  vertex,  temporal,  occipital,  or  frontal  region. 


Fig.  48. 


Fig.  49. 


Occipitofacial  bandage. 


Oblique  bandage  of  the  head. 


Oblique  Bandage  of  the  Head.  Boiler  Two  Inches  in 
Width,  Six  Yards  in  Length. — The  initial  extremity  of  the 
bandage  is  placed  upon  the  forehead,  and  is  secured  by 


BANDAGES  OF  THE  HEAD. 


53 


Fig 


two  circular  turns  passing  around  the  head  from  the  fore- 
head to  the  occiput.  From  the  occiput  the  bandage  is 
carried  obliquely  over  the  highest  part  of  the  lateral  aspect 
of  the  head,  which  is  to  be  covered  in,  and  is  passed  over 
the  forehead  and  back  to  the  occiput.  It  is  then  carried 
to  the  forehead  by  a  circular  turn,  which  is  conducted 
obliquely  over  the  other  side  of  the  head  and  back  to  the 
occiput.  A  circular  turn  from  the  occiput  to  the  forehead 
should  be  made  between  the  oblique  turns.  These  turns 
are  repeated,  so  that  each  succeeding  turn  covers  in  three- 
fourths  of  the  preceding  turn  until  the  sides  of  the  head 
are  covered  in  by  descending  turns,  and  the  bandage  is 
completed  by  a  circular  turn  passing  around  the  head  from 
the  forehead  to  the  occiput  (Fig. 
49).  This  bandage  may  be  ap- 
plied with  descending  or  ascend- 
ing turns. 

Use. — This  bandage  is  em- 
ployed to  make  pressure  upon  or 
to  hold  a  dressing  to  the  lateral 
aspects  of  the  head. 

Occipito  -  frontal  Bandage. 
Roller  Two  Inches  in  Width,  Four 
Yards  in  Length. — The  initial  ex- 
tremity of  the  roller  is  placed 
upon  the  forehead,  and  a  circular 
turn  is  made  around  the  fore- 
head and  occiput  to  fix  it.  A 
circular  turn  is  then  made,  pass- 
ing around  the  head  from  a  point 
below  the  occiput  to  a  point  just  above  the  forehead  •  the 
next  circular  turn  is  made  around  the  head  ascending 
posteriorly  and  descending  anteriorly,  and  after  a  suffi- 
cient number  of  these  turns  have  been  made  to  cover  in 
the  front  and  back  of  the  head  the  end  of  the  bandage 
is  secured  with  a  pin  (Fig.  50). 

Use. — This  bandage  will  be  found  useful  in  securing 
dressings  to  the  forehead  and  anterior  and  posterior  por- 
tions of  the  scalp. 


Occipitofrontal  bandage. 


54 


BANDAGING. 


BANDAGES  OF  THE  UPPER  EXTREMITY. 


Fig.  51. 


Spiral  Bandage  of  the  Finger.  Roller  One  Inch  in 
Width,  One  and  a  Half  Yards  in  Length. — The  initial  ex- 
tremity of  the  roller  is  se- 
cured by  two  or  three  turns 
around  the  wrist;  the 
bandage  is  then  carried 
obliquely  across  the  back 
of  the  hand  to  the  base  of 
the  finger  to  be  covered 
in,  then  to  its  tip  by  ob- 
lique turns  ;  a  circular  turn 
is  next  made,  and  the 
finger  is  covered  by  as- 
cending spiral  or  spiral 
reversed  turns  until  its 
base  is  reached  ;  the  band- 
age is  then  carried  ob- 
liquely across  the  back  of 
the  hand  and  finished  by 
one  or  two  circular  turns 
around  the  wrist ;  the  ex- 
tremity may  be  pinned  or 
which  are  tied  around  the 


■',■.';■;*  ■:■■■■■ 


Spiral  bandage  of  the  finger. 


may  be  split  into  two  tails, 
wrist  (Fig.  51). 

Use. — This  bandage  is  employed  to  retain  dressings  to 
injuries  or  wounds  upon  the  finger,  and  to  secure  splints 
in  the  treatment  of  fractures  or  dislocations  of  the 
phalanges. 

Gauntlet  Bandage.  Roller  One  Inch  in  Width,  T/iree 
Yards  in  Length. — The  initial  extremity  of  the  roller  is 
fixed  at  the  wrist  by  one  or  two  circular  turns  of  the 
bandage ;  it  is  then  carried  down  to  the  tip  of  the  thumb 
by  an  oblique  turn  of  the  roller,  and  this  is  covered  in  by 
spiral  or  spiral  reversed  turns  to  the  metacarpophalangeal 
articulations;  the  roller  is  then  carried  back  to  the  wrist 
and  a  circular  turn  is  made  around  it.     The  bandage  is 


BAX  PAGES   OF  THE    UPPER   EXTREMITY. 


55 


then  carried  down  to  the  tip  of  the  index  finger  by  an 
oblique  turn,  which  is  covered  in  the  same  manner.  When 
all  the  lingers  have  been  covered  in,  the  bandage  is  finished 
by  circular  turns  around  the  hand  and  wrist  (Fig.  52). 

Use. — This  bandage  may  be  employed  to  apply  dressings 
to  the  fingers  and  hand  in  cases  of  wounds  or  fractures. 
It  was  formerly  much  employed  in  the  treatment  of  burns 
of  the  fingers  to  prevent  the  opposed  ulcerated  surfaces 
from  adhering,  but  its  use  for  this  purpose  has  been  sup- 
planted by  wrapping  each  finger  in  a  separate  dressing  and 
applying  a  dressing  over  all  the  fingers  and  the  hand  with  a 
few  recurrent  and  spiral  turns  of  a  wide  roller,  the  applica- 
tion of  this  dressing  being  much  less  painful  to  the  patient, 


Fig.  52. 


Fig.  53. 


i^^- 


Gauntlet  bandage. 


Demi-gauntlet  bandage. 


and    being  at  the  same  time    equally  satisfactory  in   its 
results. 

Demi-gauntlet  Bandage.  Boiler  One  Inch  in  Width, 
Four  Yards  in  Length. — The  initial  extremity  of  the 
bandage  should  be  placed  upon  the  wrist  and  fixed  by  two 
circular  turns  passing  from  the  radial  to  the  ulnar  side ; 


56 


BANDAGING. 


Fig.  54. 


then  carry  the  roller  obliquely  across  the  back  of  the  hand 
to  the  base  of  the  little  finger,  pass  the  bandage  around  this 
and  carry  the  roller  back  to  the  wrist,  making  a  circular 
turn ;  it  should  then  be  carried  obliquely  across  the  hand 
to  the  base  of  the  ring  finger,  and  so  successively  until 
the  base  of  each  of  the  fingers  and  of  the  thumb  has 
been  included  ;  the  bandage  is  then  completed  by  an  oblique 
turn  across  the  back  of  the  hand  passing  between  the  index 
finger  and  the  thumb  and  a  circular  turn  around  the  wrist 
(Fig.  53). 

The  demi-gauntlet  bandage  may  also  be  applied  in  such 
a  manner  as  to  cover  only  the  palm  and  leave  the  dorsum 
of  the  hand  uncovered. 

Use. — This  bandage  may  be  employed  to  retain  light 
dressings  to  the  dorsal  or  palmar  surface  of  the  hand. 

Spica-bandage  of  the  Thumb.  Roller  One  Inch  in 
Width,  Three  Yards  in  Length. — The  initial  extremity  of 
the  roller  is  placed  upon  the  wrist 
and  fixed  by  two  circular  turns;  then 
carry  the  roller  obliquely  over  the 
dorsal  surface  of  the  thumb  to  its  distal 
extremity  ;  next  make  a  circular  or 
spiral  turn  around  the  thumb,  and 
carry  the  bandage  upward  over  the 
back  of  the  thumb  to  the  wrist,  around 
which  a  circular  turn  should  be  made. 
The  roller  is  then  carried  around  the 
thumb  and  wrist,  making  figure-of- 
eight  turns,  each  turn  overlapping 
the  previous  one  two-thirds  as  it 
ascends  the  thumb,  and  each  figure- 
of-eight  turn  alternating  with  a  cir- 
cular turn  around  the  wrist.  These 
turns  are  repeated  until  the  thumb  is 
completely  covered  in  with  spica-turns, 
and  the  bandage  is  finished  by  a  circular  turn  around  the 
wrist  (Fig.  54). 

Use. — This  bandage  is  employed  to  apply  dressings  to 
the  dorsal  surface  of  the  thumb  and  for  the  retention  of 


Spiea-bandage  of  the 
thumb. 


BANDAGES  OF  THE   UPPER   EXTREMITY.         57 

splints  in  the  dressing  of  fractures  or  dislocations  of  the 
hones  of  the  thumb. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. 
Roller  Tiro  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — The  initial  extremity  of  the  roller  is  placed  upon 
the  wrist,  and  secured  by  two  turns  around  the  wrist ;  the 
bandage  is  then  carried  obliquely  across  the  back  of  the 
hand  to  the  second  joint  of  the  fingers,  where  a  circular 
turn  should  be  made  ;  the  hand  is  covered  in  by  two  or 

Fig.  55. 


Spiral  reversed  bandage  of  the  upper  extremity. 

three  ascending  spiral  or  spiral  reversed  turns.  When  the 
thumb  has  been  reached,  its  base  and  the  wrist  are  covered 
in  by  two  figure-of-eight  turns  ;  the  bandage  is  then  carried 
up  the  forearm  by  spiral  and  spiral  reversed  turns  until  the 
elbow  is  reached ;  this  may  be  covered  in  with  spiral  re- 
versed turns,  and  the  bandage  is  next  carried  up  the  arm 
with  spiral  reversed  turns  to  the  axilla  (Fig.  55).  If,  on 
reaching  the  elbowT,  the  arm  is  bent,  or  is  to  be  flexed  in 
the  subsequent  dressing,  the  elbow  should  be  covered  in 
with  figure-of-eight  turns,  and  when  this  has  been  done 
the  arm  may  be  covered  in  with  spiral  reversed  turns. 
When  properly  applied,  the  reverses  should  be  in  line, 
and  should  not  be  made  over  the  prominent  ridge  of  the 
ulna. 

Use. — This  is  one  of  the  most  generally  employed  of  all 
the  roller-bandages  ;  it  constitutes  the  primary  roller  which 
is  applied  in  the  dressing  of  fractures  of  the  humerus,  and 


58 


BANDAGING. 


it  is  also  the  bandage  employed  in  holding  dressings  to  the 
arm  and  forearm  and  in  securing  splints  to  these  parts  in 
the  treatment  of  fractures  and  dislocations. 

Figure-of-eight  Bandage  of  the  Elbow,  Roller  Two 
Inches  in  Width,  Four  Yards  in  Length. — The  initial  ex- 
tremity of  the  bandage  is  placed  upon  the  forearm  a  short 
distance  below  the  elbow-joint,  and  fixed  by  one  or  two 

Fig.  .56. 


Figure-of-eight  bandage  of  the  elbow. 

circular  turns,  the  arm  being  flexed.  The  bandage  is  then 
carried  by  an  oblique  turn  across  the  flexure  of  the  elbow- 
joint,  and  passed  around  the  arm  a  few  inches  above  the 
elbow  ;  a  circular  turn  is  then  made,  and  the  roller  is  next 
carried  across  the  flexure  of  the  elbow  and  passed  around 
the  forearm.  These  turns  are  repeated,  the  turns  from  the 
forearm  ascending  and  those  from  the  arm  descending, 
each  set  of  turns  crossing  in  the  flexure  of  the  elbow  until 


BANDAGES  OF  THE   UPPER  EXTREMITY. 


59 


it  is  covered  in,  and  a  final  turn  is  passed  circularly  around 
the  elbow-joint  (Fig.  56).  This  bandage  is  sometimes 
applied  by  first  making  one  or  two  circular  turns  around 
the  elbow  and  then  applying  the  figure-of-eight  turns  as 
previously  described  (Fig.  57). 

Use. — This  bandage  is  often  employed  as  a  part  of  the 
spiral  reversed  bandage  of  the  upper  extremity  when  the 
arm  is  to  be  flexed,  and  is  also  used  to  hold  dressings  to 
the  region  of  the  elbow-joint.     It  was  formerly  much  used 

Fig.  57. 


Figure-of  eight  bandage  with  primary  turns  around  the  elbow. 

to  hold  the  compress  upon  the  wound  resulting  from  vene- 
section at  the  elbow. 

Spica-bandage  of  the  Shoulder  (Ascending).  Roller 
Two  and  a  Half  Inches  in  Width,  Seven  Yards  in  Length, 
—The  initial  extremity  of  the  roller  is  placed  obliquely 
upon  the  outer  surface  of  the  arm  opposite  the  axillary 
fold,  and  fixed  by  one  or  two  circular  turns.  If  the  right 
shoulder  is  to  be  covered,  the  bandage  is  next  carried  across 
the  front  of  the  chest  to  the  axilla  of  the  opposite  side, 
then  around  the  back  of  the  chest  to  the  point  of  starting 


60  BANDAGING. 

upon  the  arm  ;  then  the  roller  should  be  conducted  around 
the  arm  of  this  side  up  over  the  shoulder,  across  the  front 
of  the  chest,  through  the  opposite  axilla,  and  back  over  the 
posterior  surface  of  the  chest  to  the  point  of  starting ;  con- 
tinue to  make  these  ascending  turns,  each  turn  overlapping 
the  preceding  one  about  two-thirds  until  the  shoulder  is 
covered  in  (Fig.  58),  when  the  extremity  of  the  bandage 
may  be  secured  by  a  pin  at  the  point  of  ending,  or  the  last 
turn  may  be  carried  from  the  shoulder  around  the  back  of 
the  neck  and  brought  forward  over  the  opposite  shoulder 

Fig.  58. 


Spioa-bandage  of  the  shoulder  (ascending). 

and  pinned  to  the  turns  which  pass  around  the  axilla.  It 
should  be  remembered  that  the  turns  of  the  roller  overlap 
each  other  exactly  in  the  opposite  axilla,  and  it  will  be 
found  more  comfortable  to  the  patient  to  place  a  little 
cotton-wadding  in  the  axilla  to  prevent  the  bandage  from 
excoriating  the  skin  of  this  part.  Care  should  be  taken 
to  see  that  the  turns  are  made  in  such  a  manner  that  the 
spica-turns  occupy  as  nearly  as  possible  the  median  line 
of  the  shoulder.  When  this  bandage  is  applied  to  the 
left  shoulder,  after  fixing  the  initial  extremity  by  circular 
turns  around  the  arm,  the  roller  should  be  carried  over 


BANDAGES  OF  THE   UPPER  EXTREMITY. 


01 


the  back  of  the  chest  to  the  axilla  of  the  opposite  side  and 
then  brought  back  to  the  point  of  starting;  the  succeed- 
ing turns  are  then  applied  in  the  same  manner. 

Spica-bandage  of  the  Shoulder  (Descending).  Roller 
Two  and  a  Half  Inches  in  Width,  Seven  Yards  in  Length. — 
The  initial  extremity  of  the  roller  should  be  fixed  upon 
the  arm  as  near  as  possible  to  the  axillary  fold  by  one  or 
two  circular  turns ;  and  if  it  is  applied  to  the  right  shoul- 
der, the  bandage  should  be  passed  under  the  axilla  and 
carried  obliquely  over  the  shoulder  to  the  base  of  the  neck, 

Fig.  59. 


Spica-banda 


then  downward  across  the  front  of  the  chest  to  the  axilla 
of  the  opposite  side ;  from  the  axilla  the  roller  is  carried 
over  the  back  of  the  chest  to  the  base  of  the  neck,  so  as  to 
cross  the  first  turn  at  this  point ;  it  is  then  carried  through 
the  axillary  space,  then  back  to  the  neck,  the  turns  de- 
scending toward  the  shoulder.  These  turns,  taking  the 
same  course,  are  repeated,  each  turn  overlapping  two- 
thirds  of  the  previous  one  until  the  shoulder  is  covered  in 
and  the  circular  turn  around  the  arm  is  reached,  at  which 
point  the  extremity  is  secured  by  a  pin  (Fig.  59). 

Use. — The  spica-bandages  of  the  shoulder  are  employed 


62  BANDAGING. 

to  hold  dressings  to  the  shoulder,  to  hold  compresses  over 
the  acromial  end  of  the  clavicle  in  dislocation  of  that 
portion  of  the  bone,  to  retain  the  shoulder-cap  used  in 
the  treatment  of  fractures  of  the  upper  portion   of  the 

humerus,  and  to  retain  dress- 
Fig.  60.  ings  to  the  axilla. 

^^^^^ _.___l        Figure-of-eight,  Bandage 

;  •        B  of   the  Neck  and  Axilla. 

j v  ■■  - .    ^F  Roller  Two  Inches  in  Width, 

%  -^r  I    Five  Yards  in  Length. — The 

mp     \  initial  extremity  of  the  roller 

W  ;    is  fixed  upon  the  side  of  the 

■  neck   and  secured  by  one  or 

I  ■     two    loosely  applied   circular 

turns;  if  applied  to  the  right 

' —^ _-£._»    axilla,  carry  the  bandage  from 

Figure-oMgM  bandage  of  the        ^    tQ    right    over    the    right 

shoulder  to  the  anterior  part 
of  the  axilla  under  which  it  passes,  to  ascend  in  front  over 
the  same  shoulder  to  the  back  of  the  neck  ;  these  figure- 
of-eight  turns  around  the  neck  and  axilla,  each  turn  over- 
lapping two-thirds  of  the  preceding  turn,  are  repeated 
until  the  desired  space  is  covered  and  the  bandage  is 
completed  by  a  circular  turn  around  the  neck  (Fig.  60). 

Use. — This  will  be  found  a  useful  bandage  to  secure 
dressings  to  the  base  of  the  neck,  the  upper  part  of  the 
shoulder,  and  to  the  axilla,  as  it  does  not  restrict  the 
motions  of  the  arm  unless  drawn  too  tight. 

Velpeau's  Bandage.  Two  Rollers  Two  and  a  Half 
Inches  in  Width,  Seven  Yards  in  Length. — The  patient 
should  place  the  fingers  of  the  hand  of  the  affected  side  on 
the  opposite  shoulder ;  the  initial  end  of  the  roller  should 
be  placed  on  the  body  of  the  scapula  of  the  sound  side 
and  secured  by  a  turn  made  by  carrying  the  bandage  over 
the  shoulder  of  the  affected  side,  near  its  outer  portion, 
then  conducting  it  downward  over  the  outer  and  posterior 
surface  of  the  arm  of  the  same  side,  behind  the  point  of 
the  elbow,  and  obliquely  across  the  front  of  the  chest  to 
the  axilla  of  the  opposite  side,  thence  to  the  point  of  start- 


BANDAGES  OF  THE   UPPER    EXTREMITY. 


63 


ing.  This  turn  should  be  repeated,  to  fix  the  initial  ex- 
tremity of  the  bandage.  Having  completed  the  second 
turn,  carry  the  roller  transversely  around  the  thorax,  pass- 
ing over  the  flexed  elbow  of  the  affected  side,  from  this 
point  to  the  axilla,  and  through  this  to  the  back.  From 
this  point  the  roller  is  carried  over  the  shoulder  and 
down  the  outer  and  posterior  surface  of  the  arm  behind  the 
elbow,  and  obliquely  across  the  front  of  the  chest  through 
the  axilla  to  the  back,  and,  continuing,  passes  transversely 

Fig.  61. 


Velpeau's  bandage. 

across  the  back  of  the  chest  to  the  elbow,  which  it  en- 
circles, and  then  passes  to  the  axilla.  These  alternating 
turns  are  repeated  until  the  arm  and  forearm  are  bound 
firmly  to  the  side  and  chest.  The  vertical  turns  over  the 
shoulder,  each  turn  covering  in  two-thirds  of  the  previous 
turn  and  ascending  from  the  point  of  the  shoulder  toward 
the  neck  and  from  the  posterior  surface  of  the  arm  toward 
the  elbow,  are  applied  until  the  point  of  the  elbow  is 
reached.  The  transverse  turns  passing  around  the  chest 
and  arm  are  so  applied  that  they  ascend  from  the  point 
of  the  elbow  toward  the  shoulder,  each  turn  covering  in 


64  BANDAGING. 

one-third  of  the  previous  one,  and  the  last  turn  should 
pass  transversely  around  the  shoulder  and  chest,  covering 
the  wrist  (Fig.  61). 

The  extremity  of  the  bandage  should  be  secured  by  a 
pin  where  it  ends,  and  additional  fixation  will  be  secured 
by  introducing  a  number  of  pins  at  the  points  where  the 
turns  of  the  bandage  cross  each  other. 

Use. — This  bandage  is  employed  to  fix  the  arm  in  the 
treatment  of  certain  fractures  of  the  clavicle  and  scapula ; 
also  to  secure  fixation  of  the  humerus  after  the  reduction 
of  dislocations  of  the  shoulder-joint. 

Desault's  Bandage.  Three  Boilers  Two  and  a  Half 
Inches  in  Width,  Seven  Yards  in  Length. — A  wedge-shaped 
pad  to  fit  in  the  axilla  is  also  required.  These  rollers  are 
known  as  the  first,  second,  and  third  rollers. 

First  Roller  of  Desault's  Bandage. — Before  applying  the 
first  roller  the  arm  of  the  patient  on  the  injured  side  should 

.     Fig.  G2. 


First  roller  of  Desault's  bandage. 


be  elevated  and  carried  off  at  right  angles  to  the  body  ;  the 
wedge-shaped  pad  with  its  base  in  the  axilla  should  next 
be  applied  to  the  side  of  the  chest,  and  the  initial  extrem- 
ity of  the  roller  should  be  placed  upon  the  middle  of  the 
pad,  which  may  be  fixed  by  two  or  three  circular  turns 
around  the  chest;  the  bandage  is  then  carried  down  the 


BANDAGES  OF  THE   UPPER   EXTREMITY. 


65 


chest  by  obliqtie  circular  turns  until  the  lower  extremity 
of  the  pad  is  reached,  and  it  is  then  carried  up  the  chest 
by  spiral  turns  until  the  upper  extremity  of  the  pad  is 
reached,  when  it  is  conducted  obliquely  across  the  front 
of  the  chest  to  the  sound  shoulder  and  passed  under  the 
axilla,  brought  over  the  shoulder  and  conducted  around 
the  chest,  where  it  is  secured  (Fig.  62). 

Second  Roller  of  Desault's  Bandage. — The  arm  should  be 
brought  down  against  the  side  so  as  to  press  upon  the  pad 
previously  applied,  and  the  forearm  should  be  flexed  upon 
the  arm  and  brought  across  the  lower  portion  of  the  chest. 

Fig.  63. 


Second  roller  of  Desault's  bandage. 


The  initial  extremity  of  the  roller  is  placed  in  the  axilla 
of  the  sound  side,  and  the  bandage  is  carried  around  the 
chest  and  over  the  arm  of  the  injured  side,  making  a  cir- 
cular turn  around  the  chest  to  fix  it ;  then  spiral  turns  are 
made  around  the  chest  from  above  downward  until  the 
elbow  is  reached,  the  turns  being  more  firmly  applied  as 
they  descend,  and  when  this  point  is  reached  the  end  of 
the  bandage  is  secured.  Or  the  initial  extremity  of  the 
bandage  may  be  placed  upon  the  chest  of  the  sound  side 
and  a  circular  turn  may  be  made  to  fix  it,  and  then  spiral 
turns,  including  the  chest  and  arm,  may  be  made  from 
below  upward  until  the  axilla  is  reached  (Fig.  63). 

5 


66  BANDAGING. 

Third  Roller  of  Desault's  Bandage. — The  initial  extremity 
of  the  roller  is  placed  in  the  axilla  of  the  sound  side,  and 
the  bandage  is  carried  obliquely  over  the  front  of  the  chest 
to  the  shoulder  of  the  injured  side,  passed  over  this,  and 
conducted  down  the  back  of  the  arm  to  the  elbow,  thence 
obliquely  upward  over  the  upper  fifth  of  the  forearm  to 
the  axilla  of  the  sound  side.  From  this  point  it  is  carried 
backward  obliquely  over  the  back  of  the  chest  to  the  shoul- 
der ;  crossing  the  previous  shoulder-turn,  it  is  conducted 
down  the  front  of  the  arm  to  the  elbow,  then  around  this 
and  backward  obliquely  over  the  back  of  the  chest  to  the 

Fig.  64. 


Third  roller  of  Desault's  bandage. 

axilla  of  the  sound  side.  These  turns  are  repeated  until 
three  sets  of  turns  have  been  applied,  which  should  overlie 
each  other  exactly  (Fig.  64).  The  course  of  the  turns  of 
the  third  roller  is  considered  the  most  difficult  to  remem- 
ber, and  the  student  may  be  assisted  in  its  correct  applica- 
tion by  remembering  that  all  the  turns  start  at  the  axilla, 
pass  to  the  shoulder,  and  then  to  the  elbow,  and  from  the 
elbow  always  return  to  the  starting-point — the  axilla. 
The  turns  of  the  third  roller  make  two  triangles,  one  on 
the  anterior  surface  of  the  chest  (Fig.  65),  the  other  upon 
the  back  (Fig.  66). 

After  the  application  of  the  three  rollers  the  hand  and 


BANDAGES  OF  THE   UPPER  EXTREMITY.  <i7 

uncovered  portion  of  the  forearm  should  be  supported  in 
a  sling  suspended  from  the  neck. 

Use. — This  bandage,  applied  completely,  or  some  one  of 
its  various  rollers,  is  employed  in  the  treatment  of  fractures 
of  the  clavicle. 


Fig.  6b. 


Fig.  66. 


Anterior  view  of  the  turns  of  third 
roller  of  Desault's  bandage. 


Posterior  view  of  the  turns  of  third 
roller  of  Desault's  bandage. 


Arm-and-chest  Bandage.     Boiler  Two  and  a  Half 

Inches  in  Width,  Seven  Yards  in  Length. — Before  applying 
this  bandage,  the  arm  should  be  placed  against  the  side  of 
the  chest  and  a  folded  towel  or  a  pad  of  cotton  should  be 
placed  in  the  axilla  and  allowed  to  extend  from  the  axilla 
to  the  elbow ;  the  latter  is  used  to  prevent  the  opposing 
surfaces  of  skin  from  becoming  excoriated  by  contact. 


68 


BAND  A  GING. 


The  initial  extremity  of  the  bandage  is  plaeed  upon  the 
spine  at  a  point  opposite  the  elbow-joint,  and  it  is  fixed  by 
a  turn  or  two  passing  around  the  arm  and  chest ;  the  band- 
age is  then  continued  by  making  ascending  spiral  turns, 
covering  in  the  arm  and  chest  until  the  axilla  is  reached  ; 
at  this  point  the  bandage  is  carried  through  the  axilla  of 
the  sound  side  and  over  the  back  of  the  chest  to  the  top  of 

Fig.  67. 


Arm-and-chest  bandage. 

the  opposite  shoulder,  and  it  is  then  conducted  down  the 
front  of  the  arm  to  the  elbow,  is  passed  between  the  arm 
and  chest,  and  carried  up  the  back  of  the  arm  to  the 
shoulder.  It  is  then  passed  obliquely  across  the  front  of 
the  chest,  and  is  secured  upon  the  back  of  the  chest.  Pins 
should  be  introduced  at  the  points  of  crossing  of  the 
bandage  (Fig.  67). 


BANDAGES  OF  THE  TRUNK. 


69 


Use. — This  bandage  will  be  found  useful  in  fixing  the 
arm  to  the  body  and  in  fixing  the  shoulder-joint  where  it 
is  desirable  to  allow  the  forearm  to  be  free.  It  is  em- 
ployed in  the  treatment  of  fractures  of  the  shaft  and  neck 
of  the  humerus  to  fix  the  arm  and  hold  splints  in  position. 


BANDAGES    OF    THE    TRUNK. 

Spiral  Bandage  of  the  Chest.  Boiler  Three  Inches  in 
Width,  Nine  Yards  in  Length. — The  initial  extremity  of 
the  roller  is  applied  to  the  anterior  portion  of  the  waist, 
and  fixed  by  one  or  two  circular  turns  ;  the  bandage  is 
then  carried  upward,  encircling  the  chest  by  ascending 
spiral  turns,  each  turn  covering  in  one-half  of  the  previous 
turn  until  the  axillary  fold  is  reached  ;  the  roller  is  next 
carried  around  the  axilla  to  the  back,  and  obliquely  over 
this  to  the  base  of  the  neck  of  the  opposite  side,  and 
then  it  may  be  passed  down  over  the  chest  and  pinned 
to  the  spiral  turns  at  several  points ;  a  pin  should  also  be 
inserted  at  the  point  where  the  last  turn  of  the  roller 
leaves  the  spiral  turn  upon  the  back  of  the  chest  (Fig.  68). 

Use. — This  bandage  is  em- 
ployed to  hold  dressings  to 
the  chest,  and  may  be  used 
as  a  temporary  dressing  in 
fractures  of  the  ribs  or  ster- 
num. Care  should  be  taken 
that  the  bandage  be  not  so 
tightly  applied  as  to  interfere 
with  respiration. 

Anterior  Figure-of-eight 
Bandage  of  the  Chest. 
Roller  Two  and  a  Half  Inches 
Width,    Seven    Yards    in 


Fig. 


in 


Length. — The  initial  extrem- 
ity of  the  roller  should  be 
placed  in  the  axilla  of  one 
side,  and  the  bandage  is  then 
carried  obliquely  across  the  anterior  portion  of  the  chest 


Spiral  bandage  of  the  chest. 


70 


BANDAGING. 


to  the  shoulder  of  the  opposite  side  ;  it  is  then  carried 
backward  around  the  shoulder  and  through  the  axilla,  and 
is  next  conducted  obliquely  over  the  anterior  portion  of 
the  chest  to  the  opposite  shoulder,  through  the  axilla,  and 
again  back  to  the  anterior  portion  of  the  chest,  the  turns 
crossing  in  the  median  line  over  the  sternum.  These 
turns  should  be  repeated,  ascending  from  the  shoulder 
toward  the  neck,  each  turn  overlapping  three-fourths  of 
the  preceding  one,  until  five  or  six  turns  have  been  ap- 
plied, the  end  of  the  bandage  being  secured   by  a  pin 

Fig.  69. 


Anterior  figure-of-eight  bandage  of  the  chest. 

(Fig.  69),  or  it  may  be  completed  by  a  circular  turn 
around  the  chest. 

Use. — This  bandage  may  be  employed  to  bring  the 
shoulders  forward,  and  to  hold  dressings  to  the  anterior 
portion  of  the  chest. 

Posterior  Figure-of-eight  Bandage  of  the  Chest. 
Roller  Two  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — The  initial  extremity  of  the  roller  should  be 
placed  in  the  axilla  of  the  left  side,  and  the  bandage  should 
then  be  carried  obliquely  across  the  back  of  the  chest  to 
the  tip  of  the  opposite  shoulder ;  it  is  next  carried  through 
the  axilla  and  conducted  across  the  posterior  portion  of  the 
chest  to  the  top  of  the  opposite  shoulder,  and  passed  through 
the  axilla  to  the  point  of  starting.     These  turns  are  re- 


BANDAGES  OF  THE  TRUNK.  71 

peated,  descending  from  the  neck  toward  the  shoulder,  until 

five  or  six  have  been  applied,  the  end  of  the  bandage  being 
secured  by  a  pin  (Fig.  70).  In  applying  both  of  these 
bandages  the  crosses  of  the  bandage,  either  anterior  or 
posterior,  should  be  made  in  the  median  line  of  the 
chest. 

Use. — This  bandage  may  be  employed  to  hold  dress- 
ings to  the  posterior  portion  of  the  chest  and  to  draw  the 
shoulders  backward. 

Fig.  70. 


Posterior  figure-of-eight  bandage  of  the  chest. 

Suspensory  and  Compressor  Bandage  of  the  Breast. 
Roller  Two  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — The  initial  extremity  of  the  roller  should  be 
placed  upon  the  scapula  of  the  affected  side,  and  secured 
by  two  oblique  turns  carried  over  the  opposite  shoulder 
and  conducted  downward  under  the  breast  to  be  covered 
in,  and  then  carried  to  the  axilla  of  the  same  side.  Xext 
carry  the  roller  transversely  around  the  chest,  covering  in 
the  lowest  portion  of  the  affected  breast.  These  turns 
should  be  repeated,  the  oblique  turns  from  the  axilla  over 
the  shoulder  alternating  with  the  transverse  turns  around 
the  chest,  until  the  breast  is  covered  in,  each  series  of  turns 
ascending  and  covering  two-thirds  of  the  preceding  turns 
(Fig.  71). 


72 


BANDAGING. 


Use. — This  bandage  is  employed  to  support  the  breast 
and  to  make  compression  at  the  same  time ;  it  may  also  be 
employed  to  hold  dressings  to  the  breast. 


Fig.  71. 


Suspensory  and  compressor  bandage  of  the  breast. 


Suspensory  and  Compressor  Bandage  of  Both 
Breasts.  Two  Boilers  Two  and  a  Half  Inches  in  Width, 
Seven  Yards  in  Length. — The  initial  extremity  of  the 
bandage  should  be  secured  by  oblique  turns  of  the  axilla 
and  shoulder,  passing  under  one  breast,  as  in  the  preceding 
bandage  ;  the  roller  should  next  be  carried  transversely 
around  the  back  to  the  other  breast,  then  under  the  breast 
and  upward  over  the  opposite  shoulder,  then  obliquely 
downward  around  the  chest  to  the  other  side,  being  carried 
transversely  over  the  lower  portion  of  both  breasts  to  the 
point  of  starting  upon  the  back.  Repeat  these  oblique 
turns  from  the  shoulder  to  the  breast  and  from  the  breast 
to  the  shoulder,  and  alternate  them  with  a  transverse 
turn  around  the  chest  and  over  both  breasts.  Both  series 
of  turns  should  ascend,  and  each  turn  should  overlap 
two-thirds  of  the  preceding  one  (Fig.  72). 

Use. — This  bandage  is  employed  to  support  and  com- 
press both  breasts  and  to  retain  dressings  to  them. 


BANDAGES  OF  THE  LOWER  EXTREMITY.         73 
Fig.  72. 


Suspensory  and  compressor  bandage  of  both  breasts. 

BANDAGES    OF   THE   LOWER    EXTREMITY. 

Single   Spica-bandage  of  the   Groin  (Ascending). 

Boiler  Two  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — Place  the  initial  extremity  of  the  bandage  upon 
the  anterior  portion  of  the  right  thigh  just  below  the  groin, 
and  secure  it  by  one  or  two  circular  turns  around  the  thigh, 
or  place  the  initial  extremity  of  the  roller  obliquely  upon 
the  upper  part  of  the  thigh  and  carry  it  behind  the  limb 
and  upward  around  the  outer  side  of  the  thigh  to  the  abdo- 
men, omitting  the  circular  turns  ;  then  carry  the  bandage 


74  BANDAGING. 

obliquely  across  the  lower  part  of  the  abdomen  to  a  point 
just  below  the  crest  of  the  left  ilium,  and  conduct  it  trans- 
versely around  the  back  of  the  pelvis  to  a  corresponding 
point  on  the  opposite  side ;  then  bring  it  obliquely  down- 
ward to  the  groin  and  over  to  the  inner  portion  of  the  thigh, 
carrying  it  around  the  limb,  crossing  the  starting-turn  in 
the  middle  line  of  the  thigh.  These  turns  are  repeated, 
each  turn  ascending  and  covering  in  two-thirds  of  the  pre- 
ceding turn,  until  six  or  eight  complete  turns  have  been 
made,  and  the  bandage  is  then  secured  at  any  point  where 
it  ends  (Fig.  73).     This  bandage  may  also  be  applied  by 


Ascending  spica-bandage  of  the  groin. 

placing  the  initial  extremity  of  the  bandage  just  below  the 
anterior  superior  spinous  process  of  the  ilium,  and  making 
two  turns  around  the  pelvis  and  then  carrying  the  bandage 
to  the  thigh  below  the  groin,  passing  it  behind  the  thigh, 
bringing  it  up  on  the  opposite  side  of  the  thigh  to  cross 
the  first  turn  in  the  middle  line  of  the  groin  ;  ascending 
spica-turns  are  then  made  until  a  sufficient  number  have 
been  applied  to  cover  in  the  groin  to  the  desired  extent 
(Fig.  74).  This  bandage  possesses  the  advantage  that  it 
is  less  likely  to  become  displaced  than  the  one  previously 
described. 


BANDAGES  OF  THE  LOWER   EXTREMITY 


75 


Single  Spica-bandage  of  the  Groin  (Descending). 
Roller  Tiro  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — Place  the  initial  extremity  of  the  roller  obliquely 
upon  the  anterior  surface  of  the  right  thigh  and  secure  it 
by  one  or  two  circular  turns  around  the  limb,  or  start  the 
bandage  with  an  oblique  turn,  as  previously  described ; 
then  carry  the  bandage  obliquely  across  the  abdomen  to 
a  point  just  below  the  crest  of  the  ilium,  and  conduct  it 
transversely  around  the  back  of  the  pelvis  to  a  correspond- 
ing point  on  the  opposite  side  ;  then  bring  it  obliquely 


Fig.  74. 


Fig.  75. 


Ascending  spica-bandage  of  the  groin  ap-        Descending  spica-bandage  of  the 
plied  with  pelvic  turns.  groin. 

down  over  the  lower  portion  of  the  abdomen,  crossing  the 
first  turn,  to  the  junction  of  the  thigh  with  the  scrotum, 
pass  it  under  the  thigh  and  bring  it  up  over  the  lower 
part  of  the  abdomen,  and  let  it  follow  the  course  of  the  first 
turn.  These  turns  are  repeated,  each  turn  descending  and 
overlapping  two-thirds  of  the  preceding  turn  until  the  groin 
is  covered  (Fig.  75).  When  either  of  these  bandages  is 
applied  to  the  left  groin,  after  the  initial  extremity  of  the 
roller  is  fixed,  it  is  carried  first  to  the  crest  of  the  ilium 
of  the  same  side,  then  around  the  back  of  the  pelvis  to  a 
corresponding  point  on  the  opposite  side,  then  obliquely 


76  BAND  A  GING. 

across  the  lower  part  of  the  abdomen  to  the  outer  aspect 
of  the  thigh,  being  conveyed  around  this  and  brought  up 
between  the  thigh  and  the  scrotum,  passing  obliquely  over 
the  groin  to  follow  the  course  of  the  original  turn.  This 
bandage  may  also  be  applied  by  making  one  or  two  cir- 
cular turns  around  the  pelvis,  and  the  groin  is  next  cov- 
ered in  by  descending  spica-turns. 

Double  Spica-bandage  of  the  Groins.  Roller  Three 
Inches  in  Width,  Nine  Yards  in  Length. — The  initial  ex- 
tremity of  the  roller  is  placed  upon  the  abdomen  just  above 

the  iliac  crests  and  secured 
Fig.  76.  by  one  or  two  circular  turns ; 

the  bandage  is  then  carried 
from  a  point  just  below  the 
crest  of  the  right  ilium  ob- 
liquely across  the  lower  por- 
tion of  the  abdomen  to  the 
outer  portion  of  the  left 
thigh,  is  carried  around  this 
and  brought  up  between  the 
scrotum  and  the  thigh,  and 
is  passed  obliquely  over  the 
groin,  crossing  the  previous 
turn  in  the  median  line,  and 
K  is  conducted  to  a  point  just 

below  the  crest  of  the  ilium 

Double  spica-bandage  of  the  groins.  On     the     Same      side.        The 

bandage  is  then  continued 
around  the  pelvis  to  the  same  point  on  the  opposite  side, 
and  from  this  point  is  made  to  pass  obliquely  over  the 
groin  to  the  inner  side  of  the  right  thigh,  passing  around 
this  and  coming  up  on  its  outer  side,  crossing  the  preceding 
turn  at  the  middle  line  of  the  groin,  to  be  carried  obliquely 
across  the  groin  and  lower  part  of  the  abdomen  to  the 
crest  of  the  ilium  on  the  opposite  side.  These  turns  are 
repeated,  each  turn  covering  in  two-thirds  of  the  previous 
turn,  until  both  groins  have  been  covered  (Fig.  76).  The 
turns  may  be  so  applied  as  to  ascend  or  descend,  forming 
the  ascending  or  descending  double  spica-bandage  of  the 


BANDAGES  OF  THE  LOWER   EXTREMITY. 


77 


Fig 


groins.     When   properly   applied,   this   bandage   presents 
three  sets  of  crossing-turns,  one  in  each  groin  and  one  in 

the  median  line  of  the  abdomen. 

Use. — The  spica-bandages  of  the  groin,  either  single  or 
double,  are  employed  to  hold  dressings  to  wounds  in  the 
inguinal  region — for  instance,  those  resulting  from  herni- 
otomy,  or  from  operations  upon  the  glands  of  the  groin. 
They  are  also  employed  to  make  pressure  upon  this  region, 
and  will  often  prove  of  use  in  the  securing  of  compresses 
applied  for  the  temporary  retention  of  hernia?. 

Spica-bandage  of  Buttock.  Rolkr  Two  and  a  Half 
Inches  in  Width,  Seven  Yards  in  Length. — The  initial  ex- 
tremity of  the  bandage  is 
placed  upon  the  back  of  the 
thigh  just  below  the  gluteal 
fold,  and  is  carried  around  the 
thigh  and  brought  back  to  the 
posterior  aspect  of  the  limb,  so 
as  to  fix  and  cross  the  starting- 
turn  near  the  middle  of  the 
thigh.  It  is  next  conducted 
obliquely  across  the  thigh  and 
buttocks  and  carried  to  the 
brim  of  the  pelvis  of  the  op- 
posite side,  when  it  is  brought 
obliquely  over  the  abdomen 
and  back  to  the  posterior  sur- 
face of  the  thigh.  These  as- 
cending  turns  are  applied, 
each  turn  covering  in  about 
three-fourths  of  the  preced- 
ing one,  until  the  buttock  is 
covered,  and  the  bandage  is  then  finished  bv  one  or  two 
circular  turns  around  the  pelvis  and  abdomen  (Fig.  7 i   . 

Use. — This  bandage  is  employed  to  hold  dressings  to  the 
upper  posterior  portion  of  the  thigh,  or  the  buttock. 

Figure-of-eight  Bandage  of  the  Knee.  Roller  Two 
nnd  a  Half  Inches  in  Width,  Firs  Yards  in  Length. — The 
initial  extremity  of  the  roller  is  placed  upon  the  right  thigh 


Spica-bandage  of  buttock. 


78 


BANDAGING. 


three  inches  above  the  patella  and  secured  by  two  or  three 
circular  turns ;  then  conduct  the  bandage  over  the  outer 
condyle  of  the  femur  across  the  popliteal  space  to  the  inner 
border  of  the  tibia  and  around  the  anterior  surface  below 
the  tubercle  and  head  of  the  fibula,  and  make  one  circular 
turn  ;  the  roller  should  then  be  carried  obliquely  across  the 
popliteal  space  to  the  inner  condyle  of  the  femur,  crossing 
the  previous  turn ;  then  carry  it  around  the  front  of  the 
thigh  to  the  outer  condyle ;  repeat  these  turns,  ascending 
toward  the  knee  from  the  leg  and  descending  from  the 
thigh  toward  the  knee,  and  finish  the  bandage  by  a  circu- 
lar turn  over  the  patella  (Fig.  78). 

Fig.  78. 


Figure-of-eight  bandage  of  the  knee. 

This  bandage  may  also  be  applied  by  making  two  circu- 
lar turns  around  the  patella  and  popliteal  space,  and  then 
carrying  the  bandage  to  the  thigh  three  inches  above  the 
patella,  and  finishing  it  with  descending  turns  from  the 
thigh  and  ascending  turns  from  the  tibia,  making  all  turns 
cross  in  the  popliteal  space  (Fig.  79). 

Use. — This  bandage  is  employed  to  hold  dressings  to  the 
knee-joint  either  anteriorly  or  posteriorly.  These  figure- 
of-eight  turns  are  often  employed  in  covering  the  knee  in 
applying  the  spiral  reversed  bandage  of  the  lower  ex- 
tremity when  it  is  desired  that  the  patient  be  allowed  to 
bend  the  knee. 


BANDAGES  OF  THE  LOWER  EXTREMITY.         79 

Fig.  79. 


Figure-of-eight  bandage  of  the  knee. 

Figure-of-eight  Bandage  of  Both  Knees.  Roller  Two 
and  a  Half  Inches  in  Width,  Seven  Yards  in  Length. — Place 
the  knees  of  the  patient  together  with  a  compress  between 
them  ;  then  place  the  initial  extremity  of  the  roller  upon 
one  thigh,  about  three  inches  above  the  patella,  and  se- 
cure it  by  one  or  two  circular  turns  around  both  thighs; 
then  conduct  the  roller 
from  the  outer  condyle  of 
the  left  femur  obliquely 
across  the  popliteal  spaces 
of  both  legs  to  the  head 
of  the  fibula  on  the 
opposite  side,  making  a 
circular  turn  around  both 
legs  ;  pass  the  roller  from 
the  head  of  the  fibula  on 
the  opposite  side  across 
the  popliteal  space  to  the 
external  condyle  opposite 
the  point  of  starting. 

Repeat  these  turns,  descending  from    the  thighs   and 
ascending  from   the   legs,  until   the   knees  are   covered, 


Figure-nf-eiffht  bandage  of  both  knees. 


80 


BANDAGING. 


and  finish  the  bandage  by  carrying  a  turn  of  the  bandage 
at  right  angles  to  the  preceding  turns  between  the  thighs 
and  the  legs  (Fig.  80). 

Use. — This  bandage  is  employed  to  secure  fixation  of 
the  limbs  after  operations  upon  the  perineum,  and  may  also 
be  employed  to  obtain  temporary  fixation  of  the  limbs  in 
transporting  cases  of  fracture  of  the  femur,  and  after  the 
reduction  of  dislocations  of  the  head  of  that  bone. 

Spica-bandage  of  the  Foot.  Boiler  Two  and  a  Half 
Inches  in  Width,  Five  Yards  in  Length. — Fix  the  initial 
extremity  of  the  roller  upon  the  ankle  and  secure  it  by 
two  circular  turns ;  then  carry  the  bandage  obliquely  over 
the  dorsum  of  the  foot  to  the  metatarso-phalangeal  articu- 
lation, and  make  a  circular  turn  around  the  foot  at  this 
point ;  then  continue  it  upward  over  the  metatarsus  by 
making  two  or  three  spiral  reversed  turns ;  next  carry  the 
bandage  parallel  with  the  inner  or  outer  margin  of  the  sole 
of  the  foot,  according  to  whether  it  is  applied  to  the  right 

or  left  foot,  directly  across  the  pos- 
terior surface  of  the  heel ;  thence 
along  the  opposite  border  of  the 
foot  and  over  the  dorsum,  crossing 
the  original  turn  in  the  median 
line  of  the  foot.  This  completes 
the  first  spica-turn.  These  spica- 
turns  are  repeated,  gradually  as- 
cending by  allowing  each  turn  to 
cover  in  three-fourths  of  the  pre- 
ceding turn,  until  the  foot  is  cov- 
ered in  with  the  exception  of  the 
posterior  portion  of  the  sole  of 
the  heel  (Fig.  81).  Care  should 
be  taken  to  see  that  the  turns  cross 
each  other  in  the  median  line,  and 
that  they  are  kept  parallel  to  each 


Fig.  81. 


Spica-bandage  of  the  foot. 


other  throughout  their  course. 

bandage    will    be 


Use.— This 

found  very  useful  when   it   is  desired  to  make  firm  com- 
pression upon  the  foot  or  to  retain  dressings  to  it;  it  is 


BANDAGES  OF  THE  LOWER  EXTREMITY.         81 

especially  useful   id   the  treatment  of  sprains  of  the  ankle 
or  the  anterior  tarsus. 

Bandage  of  Foot  Covering  the  Heel  ( American;. 
Boiler  Tiro  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — The  initial  extremity  of  the  roller  is  placed  upon 
the  leg  just  above  the  malleoli  and  fixed  by  two  circular 
turns  around  the  leg  ;  the  baudage  is  then  carried  obliquely 
across  the  dorsum  of  the  foot  to  the  metatarsophalangeal 
articulation,  at  which  point  a  circular  turn  is  made ;  two 


Fig.  82. 


Fig.  83. 


Bandage  of  foot  covering  the  heel. 


Bandage  of  foot  not  covering  the  heel. 


or  three  spiral  or  spiral  reyersed  turns  are  then  made, 
ascending  the  foot ;  the  roller  is  next  carried  directly  oyer 
the  point  of  the  heel  and  continued  back  to  the  dorsum  of 
the  foot ;  thence  beneath  the  instep  around  one  side  of  the 
heel  and  up  oyer  the  instep  ;  from  this  point  it  is  carried 
beneath  the  instep  around  the  other  side  of  the  heel  and 
up  in  front  of  the  ankle,  from  which  point  it  may  be  con- 
tinued up  the  leg  (Fig.  82). 

Use. — This  bandage  is  employed  to  coyer  in  the  foot,  and 
retain  dressings  to  the  foot  and  heel. 


82  BANDAGING. 

Bandage  of  Foot  Not  Covering  the  Heel  (French). 

Roller  Two  and  a  Half  Inches  in  Width,  Seven  Yards  in 
Length. — Fix  the  initial  extremity  of  the  roller  upon  the 
leg  just  above  the  malleoli  and  secure  it  by  two  circular 
turns  around  the  leg  ;  the  bandage  is  then  carried  obliquely 
across  the  dorsum  of  the  foot  to  the  metatarso-phalangeal 
articulation,  and  at  this  point  a  circular  turn  should  be 
made.  The  roller  is  now  carried  up  the  foot,  covering  it 
in  with  two  or  three  spiral  reversed  turns,  and  at  this 
point  a  figure-of-eight  turn  is  made  around  the  ankle  and 
instep ;  this  should  be  repeated  once,  which  will  cover  in 
the  foot  with  the  exception  of  the  heel ;  the  bandage  may 
then  be  continued  up  the  leg  with  spiral  reversed  turns 
(Fig.  83). 

Use. — This  bandage  may  be  employed  to  secure  dressings 
to  the  foot,  and  is  the  one  generally  used  to  cover  this  part 
in  applying  the  spiral  reversed  bandage  of  the  lower 
extremity. 

Spiral  Reversed  Bandage  of  the  Lower  Extremity. 
Roller  Two  and  a  Half  Inches  in  Width,  Seven  Yards  in 

Fig.  84. 


Spiral  reversed  bandage  of  the  lower  extremity. 

Length. — The  initial  extremity  of  the  roller  is  placed 
upon  the  leg  just  above  the  malleoli  and  secured  by 
two  circular  turns.  It  is  then  carried  obliquely  over 
the  foot  to  the  metatarso-phalangeal  articulation,  where 
a  circular  turn  is  made  around  the  foot.     Two  or  three 


BANDAGES  OF  THE  LOWER  EXTREMITY.         Hi] 

spiral  reversed  and  two  figure-of-eight  turns  of  the 
ankle  and  instep  should  be  made,  while  just  above  the 
ankle  one  or  two  circular  or  spiral  turns  are  made  around 
the  leg,  and  as  the  bandage  is  carried  up  the  leg,  as  it 
increases  in  diameter,  spiral  reversed  turns  are  made  until 
it  approaches  the  knee ;  at  this  point,  if  the  limb  is  to  be 
kept  straight,  the  spiral  reversed  turns  may  be  continued 
over  this  region  and  up  upon  the  thigh.  If  the  knee  is 
to  be  bent,  figure-of-eight  turns  may  be  applied  until  the 
knee  is  covered,  and  then  the  thigh  may  be  covered  with 
spiral  reversed  turns  (Fig.  84).  To  cover  in  the  thigh  as 
well  as  the  leg,  two  bandages  of  the  dimensions  before 
given  will  be  required.  Care  should  be  taken  to  keep  the 
reverses  in  a  line,  and  not  to  make  them  over  the  spine  of 
the  tibia,  as  they  may  thus  become  painful  to  the  patient. 

Use. — This  is  one  of  the  most  frequently  employed  of 
the  roller-bandages ;  it  is  used  to  apply  pressure  to  the 
lower  extremity,  to  re- 
tain dressings,  and  to  Hpf  %  „  FlG-  S5- 
secure  splints  in  the 
treatment  of  fractures 
and  dislocations. 

Figure-of-eight 
Bandage  of  the  Leg. 
Roller  Two  and  a  Half 
Inches  in  Width,  Seven 
Yards  in  Length .  — 
This  bandage  differs 
from  the  spiral  reversed 
bandage  of  the  lower 
extremity  only   in    the  " 

fact  that  when  the  swell 
of  the  calf  is  reached 
figure-of-eight  turns  are 
made  around  the  leg  in- 
stead of  spiral  reversed 

turns.      In  applying  the  Figure-of-eight  bandage  of  the  leg. 

roller,  when  the  calf  of 

the  leg  is  reached  the  bandage  is  carried  obliquely  around 


■A    I 


84 


BANDAGING. 


the  leg  to  the  crest  of  the  tibia  and  then  made  to  cross  the 
starting-turn  in  the  median  line ;  these  descending  and 
ascending  turns  are  repeated  until  the  calf  of  the  leg  has 
been  covered  in,  and  the  bandage  is  finished  with  one  or 
two  circular  turns  just  below  the  knee  (Fig.  85). 

Use. — This  bandage  holds  its  place  more  firmly  than 
the  ordinary  spiral  reversed  bandage  of  the  leg,  and  may 
be  employed  in  the  treatment  of  ulcers  of  the  leg  in  con- 
junction with  strapping,  where  it  is  desirable  to  change  the 
dressings  at  infrequent  intervals  and  to  allow  the  patient 
to  walk  about  during  the  course  of  treatment. 


SPECIAL  BANDAGES. 


Spiral  Reversed  Bandage  of  the  Penis.   Roller  Three- 
quarters  of  an  Inch  in   Width,  Thirty  Inches  in  Length. 
— Fix  the  initial  extremity  of  the  roller  by  two  circular 
-p     q  turns  around  the  penis  close 

to  the  pubis  ;  then  carry  the 
bandage  obliquely  down  to 
the  corona  glandis;  from  this 
point  ascend  the  body  of  the 
penis  by  spiral  reversed  turns 
to  the  pubis,  and  finish  the 
bandage  by  two  figure-of- 
eight  turns  around  the  neck 
of  the  scrotum  and  root  of  the 
penis,  or  split  the  end  of  the 
bandage  so  as  to  form  two 
tails,  and  secure  it  by  tying 
these  around  the  root  of  the 
penis  (Fig.  86). 

Recurrent  Bandage  of  a 
Stump.  Boiler  Two  and  a 
Half  Inches  in  Width,  Five 
to  Seven  Yards  in  Lcnc/th. 
— Place  the  initial  extremity  of  the  roller  upon  the  anterior 
or  posterior  surface  of  the  limb  a  few  inches  above  the 


Spiral  reversed  bandage  of  the  penis. 


SPECIAL  BANDAGES. 


85 


extremity  of  the  stump,  and  carry  the  bandage  to  the  end 
of  the  stump,  and  then  conduct  it  upward  or  downward 
on  the  limb,  as  the  case  may  be,  to  a  point  directly  oppo- 
site the  point  of  starting ;  then  bring  the  bandage  back 
over  the  face  of  the  stump  to  the  point  of  starting,  and 
continue  these  recurrent  turns,  each  turn  overlapping  two- 
thirds  of  the  preceding  one,  until  the  face  of  the  stump  is 
covered  ;  then  reverse  the  bandage  and  secure  the  recur- 
rent turns  at  their  points  of  origin  by  two  or  three  circular 
turns.  The  roller  should  next  be  carried  obliquely  down  to 
the  end  of  the  stump,  and  a  circular  turn  should  be  made 

Fig.  87. 


Recurrent  bandage  of  a  stump. 

around  this.  The  bandage  should  then  be  carried  up  the 
limb  by  spiral  or  spiral  reversed  turns  beyond  the  point  at 
which  the  recurrent  turns  terminated,  and  secured  by  one 
or  two  circular  turns  (Fig.  87). 

In  applying  this  bandage  to  very  short  stumps  result- 
ing from  amputations  at  or  near  the  shoulder-  or  hip-joint, 
after  making  the  recurrent  and  spiral  turns,  it  will  be 
found  necessary  to  carry  the  bandage,  in  the  case  of  am- 
putations of  the  shoulder,  across  the  chest  to  the  opposite 
axilla  and  back,  and  apply  several  of  these  turns ;  so  in 
case  of  hip  amputations  it  will  be  found  best  to  finish  the 
bandage  with  a  few  turns  about  the  pelvis. 


86 


BANDAGING. 


Bandage  for  Securing  the  Hands  and  Feet  in  the 
Lithotomy  Position. — The  hand  of  the  patient  should  be 
brought  down  and  made  to  grasp  the  outer  side  of  the 
foot ;  the  initial  extremity  of  the  roller  is  fixed  by  two 
circular  turns  around  the  wrist  and  ankle,  and  the  bandage 
is  then  passed  around  the  foot  and  hand,  and  these  turns 
are  alternated  with  turns  around  the  wrist  and  ankle  until 
the  hand  and  foot  are  firmly  secured.  The  same  proced- 
ure is  adopted  with  the  hand  and  foot  of  the  opposite  side 
(Fig.  88). 


Fig. 


Fig.  89. 


Bandage  for  securing  the  hands 
and  feet  for  lithotomy. 


Liebreich's  eye-bandage. 


Liebreich's  Eye -bandage. — This  bandage  consists  of 
a  strip  of  flannel  two  and  a  half  inches  in  width  and  from 
six  to  ten  inches  in  length,  to  the  extremities  of  which 
tapes  are  sewed.  It  may  be  applied  transversely  so  as  to 
cover  both  eyes,  or  obliquely  so  as  to  cover  only  one  eye  ; 
it  is  secured  by  the  tapes  carried  around  the  head  and  tied 
over  the  forehead  (Fig.  89). 

Use. — This  bandage  is  used  to  hold  compresses  or 
dressings  to  the  eye  or  eyes ;  the  elasticity  of  the  flannel 


SPK<  IAL   11ASDAQES. 


permits  of  its  being  applied   so  as  to   make   a   variable 
amount  of  pressure. 

Borsch's  Eye-bandage. — This  bandage  is  employed  for 
holding  a  dressing  to  one  eve.  and  consists  in  a  strip  of 
flannel,  two  or  two  and  a  half  inches  in  width,  which  is 
passed  around  the  head  from  the  occiput  and  covers  both 
eyes  (Fig.  90).  A  narrow  strip  of  flannel  is  attached  to 
the  posterior  portion,  which  is  carried  over  the  head  and 
passed  under  the  horizontal  strip  in  front  of  the  eye  which 
is  to  be  left  uncovered,  and  is  then  folded  back  so  as  to  raise 
the  horizontal  strip  from  the  eye,  and  secured  (Fig.  91). 


Fig.  90. 


Fig.  91. 


Application  of  Borsch's  eye-bandage. 

Bandage  of  Scultetus. — This  is  a  compound  bandage, 
consisting  of  a  number  of  pieces  of  muslin,  and  may  be 
prepared  from  a  two  and  a  half  or  three  inch  roller  by 
cutting  off'  strips  sufficiently  long  to  encircle  the  part  about 
one  and  one-third  times.  The  strips  are  placed  under  the 
part  in  such  a  manner  that  the  first  piece  shall  be  over- 
lapped by  the  second,  the  second  by  the  third,  and  so  on 
from  below  upward ;  the  pieces  are  then  brought  around 
the  limb,  and  the  extremities  of  the  last  piece  are  secured 
by  pins  (Fig.  92).  This  bandage  was  formerly  much  em- 
ployed in  the  treatment  of  compound  fractures  to  secure 
dressings  to  the  wound,  and  possessed  the  advantage  that 


88 


BANDAGING. 


when  a  single  strip  became  soiled  it  could  he  removed  with- 
out disturbing  the  whole  dressing,  the  new  strip  to  be  in- 
troduced being  pinned  to  the  extremity  of  the  soiled  piece 
to  be  removed,  and  then  being  drawn  through  by  its  re- 
moval. This  bandage  will  often  be  found  convenient  in 
applying  dressings  to  cases  of  excision  of  the  joints,  where 
as  little  disturbance  of  the  parts  as  possible  is  important 
in  dressing  the  wound.  When  the  strips  are  attached  to 
each  other  by  a  thread  passed  through  the  centre  of  each 
strip,  the  bandage  is   known   as  Pott's   bandage.     It   is 

Fig.  92. 


Bandage  of  Scultetus. 

applied  and  secured  in  the  same  manner,  but  it  possesses 
no  advantages  over  the  bandage  of  Scultetus. 

Gauze  Bandages. — Bandages  may  be  prepared  from 
gauze,  the  same  material  that  is  used  for  gauze  dressings, 
and  are  now  very  extensively  used  in  surgical  practice. 
The  gauze  bandages  are  prepared  by  cutting  or  tearing 
the  material  into  strips  varying  in  width  from  two  inches 
to  three  inches,  and  in  length  from  five  yards  to  eight 
yards ;  these  strips  are  then  wound  so  as  to  form  roller- 
bandages.  Gauze  bandages  are  sometimes  employed  in 
the  dressing  of  fractures,  but  do  not  furnish  as  substantial 
a  dressing  as  the  ordinary  muslin  bandages.     They,  how- 


SPECIAL  BANDAGES. 


89 


ever,  constitute  a  soft  and  comfortable  material  for  hold- 
ing dressings  to  wounds.     They  are  applied  in  the  same 

manner  as  the  ordinary  muslin  rolk-r,  with  the  exception 
that  in  their  application  reverses  are  seldom  required,  as 
the  open  mesh  of  the  bandage  gives  it  considerable  elas- 
tieitw  so  that  the  bandage  can  be  made  to  adapt  itself  to 
the  part  without  making  reverses.  Any  of  the  ordinary 
bandages  which  have  been  previously  described  may  be 

Fig.  93. 


Gauze  bandage  of  head  and  neck. 

applied  by  means  of  the  gauze  bandages,  such  as  those  of 
the  head,  extremities,  and  trunk. 

In  applying  dressings  to  wounds  of  the  head  and  neck,  it 
is  advisable  to  cover  in  both  the  head  and  neck,  and  also  to 
make  a  few  turns  over  the  upper  part  of  the  chest  and  around 
each  shoulder,  which  prevents  the  turns  of  the  bandage 
from  slipping  and  holds  the  dressing  in  place,  so  that  it 
cannot  be  disarranged  by  movements  of  the  patient  (Fig.  93). 


90  BANDAGING. 

Flannel  Bandage. — These  bandages  are  prepared  from 
flannel,  which  is  cut  into  strips  from  two  to  four  inches  in 
width  and  from  five  to  seven  yards  in  length.  These 
strips  are  formed  into  rollers  either  by  hand  or  by  means 
of  the  bandage-winder.  Flannel  bandages,  by  reason  of 
the  elasticity  which  they  possess,  can  be  applied  without 
reverses,  and  are  used  to  make  a  moderate  amount  of  elastic 
pressure.  They  are  often  employed  in  applying  dressings 
to  the  head,  especially  after  operations  upon  the  eyes,  and 
are  generally  applied  as  a  primary  roller  before  the  appli- 
cation of  plaster-of-Paris  dressings,  and  may  also  be  used 
in  subacute  joint-affections,  both  to  protect  the  parts  and 
to  make  a  moderate  amount  of  elastic  pressure. 

Black  Muslin  Bandages. — From  the  fact  that  dark- 
colored  bandages  are  less  conspicuous  than  white  ones, 


Fig.  94. 

BSBdb 

Black  muslin  bandage. 


they  are  sometimes  prepared  from  black  or  brown  muslin. 
For  this  reason  they  may  be  used  for  bandages  of  the 
head,  hand,  or  arm  in  patients  who  are  treated  as  walking 
cases,  and  who  object  to  the  conspicuousness  of  a  white 
bandage  (Fig.  94). 

The  Rubber  Bandage. — This  bandage,  which  was  in- 
troduced to  the  profession  by  Dr.  Martin,  of  Boston,  is 


SPECIAL  BANDAGES. 


91 


made  from  a  strip  of  rubber-sheeting,  from  one  inch  to 
four  inches  in  width  and  from  three  to  five  yards  in 
length,  which,  for  convenience  of  application,  is  rolled 
into  a  cylinder.  It  will  be  found  a  useful  form  of  dress- 
ing where  it  is  considered  desirable  to  apply  elastic  pr<  — 
ure  to  a  part  (Fig.  95). 

It  may  be  employed  in  the  treatment  of  varicose  veins 
of  the  legs,  in  chronic  ulcers  of  those  parts  where  pressure 
is  an  important  element  in  the  treatment,  and  may  be  used 
as  a  substitute  for  strapping  to  secure  this  object.  Its 
application  has  also  been  recommended  in  the  treatment 

Fig.  95. 


Martin's  rubber,  bandage. 

of  swelled  testicle  in  that  stage  of  the  affection  in  which 
pressure  is  indicated. 

For  application  to  the  leg,  a  rubber  bandage  two  and  a 
half  inches  in  width  and  three  yards  in  length  is  required. 

The  initial  extremity  of  the  roller  is  fixed  upon  the  foot 
near  the  toes  and  secured  by  a  circular  turn ;  the  foot  is 
then  covered  in  by  spiral  turns  overlapping  each  other 
about  two-thirds,  and  a  figure-of-eight  turn  is  made  from 
the  ankle  to  the  instep.  The  bandage  is  then  carried  up 
the  limb  to  the  knee  with  spiral  turns,  where  it  is  secured 
by  two  tapes  sewed  to  the  terminal  extremity  of  the  band- 
age, which  are  passed  around  the  leg  and  tied.  The  band- 
age need  not  be  reversed,  as  its  elasticity  allows  it  to  con- 
form to  the  shape  of  the  limb.  Care  should  be  taken  not 
to  apply  the  turns  with  too  much  firmness ;  the  bandage 
should  be  stretched  very  slightly ;  if  this  precaution   is 


92  BANDAGING. 

not  taken,  it  soon  becomes  uncomfortable  to  the  patient. 
A  patient  using  one  of  these  bandages  will  soon  learn  to 
apply  it  himself,  making  just  the  requisite  amount  of  ten- 
sion to  secure  its  holding  its  place,  and  to  insure  a  com- 
fortable degree  of  pressure  upon  the  part.  A  well-fitting 
stocking  may  be  placed  upon  the  limb  before  the  bandage 
is  applied,  or  it  may  be  applied  directly  to  the  skin. 

The  bandage  should  be  removed  at  night  when  the 
patient  goes  to  bed  and  hung  up  to  dry,  as  its  inner  sur- 
face becomes  moist  from  the  secretions  from  the  skin ;  it 
should  be  reapplied  as  soon  as  the  patient  rises  in  the 
morning. 

In  using  it  in  the  treatment  of  ulcers  of  the  leg  no  oint- 
ment should  be  applied  to  the  ulcer,  as  oily  dressings  soon 
destroy  the  rubber ;  applications  may  be  made  to  the  ulcer 
by  means  of  dry  powders,  such  as  oxide  of  zinc,  iodoform, 
or  aristol,  before  the  bandage  is  applied. 

In  the  treatment  of  swelled  testicle  the  bandage  is  ap- 
plied to  the  testicle  by  means  of  recurrent  turns  not  too 
firmly  made,  and  secured  in  place  by  spiral  turns,  until  the 
whole  surface  of  the  organ  is  covered  in  ;  the  end  of  the 
bandage  is  secured  with  tapes  tied  around  the  root  of  the 
scrotum.  The  same  precaution  to  apply  the  bandage  so 
as  to  make  only  moderate  pressure  should  also  be  observed 
here. 

Elastic-webbing  Bandage. — This  bandage,  which  is 
woven  from  threads  of  rubber  covered  with  cotton  or  silk, 
has  recently  been  introduced,  and  possesses  all  the  advan- 
tages of  the  rubber  bandage  as  regards  elasticity,  and  has 
the  additional  advantage  that  air  can  circulate  through  the 
meshes  of  the  bandage  and  moisture  can  evaporate  from 
the  surface  covered  by  the  bandage,  so  that  the  skin  cov- 
ered by  it  does  not  become  bathed  in  perspiration,  as  is 
the  case  with  the  rubber  bandage.  It  is  applied  in  the 
same  manner  and  for  the  same  purposes  as  the  rubber 
bandage.  The  patient  soon  learns  to  apply  it  himself,  so 
as  to  make  the  requisite  amount  of  pressure.  In  the  treat- 
ment of  varicose  veins,  and  oedema  of  the  legs  we  have 
found  it  a  most  satisfactory  dressing. 


FIXED  DRESSINGS,   OR  HARDENING   BANDAGES. 


FIXED    DRESSINGS,    OR    HARDENING    BANDAGES. 

For  the  application  of  these  dressings  a  variety  of 
substances  are  used  which  are  incorporated  in  the  meshes 
of  some  fabric,  such  as  crinoline  or  cheese-cloth,  or  painted 
over  its  surface  to  give  fixity  or  solidity  to  the  bandage. 

The  materials  most  commonly  used  in  the  preparation 
of  fixed  dressings  are  plaster-of- Paris,  starch,  silicate  of 
sodium  or  potassium,  and  paraffin. 

Plaster-of-Paris  Dressings. 

The  plaster-of- Paris  used  for  the  application  of  surgical 
dressings  should  be  of  the  same  quality  as  that  which 
dental  surgeons  employ  in  taking  casts  for  teeth — that  is, 
the  extra-calcined  variety.  If  moist  or  of  inferior  quality, 
it  will  not  set  rapidly  or  firmly,  and  will  fail  to  give  suffi- 
cient fixation  to  the  dressing. 

Methods  of  Applying  Plaster-of-Paris  Dressings. — 
The  plaster-of-Paris  dressing  may  be  applied  in  several 
ways,  either  by  covering  the  part  to  be  enclosed  with  some 
loose  fabric,  and  rubbing  the  moist  plaster  into  it,  alter- 
nating the  layers  of  the  fabric  with  layers  of  moist  plaster, 
or  it  may  be  applied  by  means  of  a  roller  which  has  been 
prepared  by  incorporating  plaster-of-Paris  in  its  meshes. 

It  may  also  be  applied  in  the  form  of  the  Bavarian 
dressing  (page  100),  or  in  the  form  of  moulded  plaster-of- 
Paris  splints  (page  102). 

To  apply  a  plaster-of-Paris  dressing  according  to  the  first 
method,  the  part  to  be  enclosed — the  leg,  for  instance — 
should  first  be  covered  by  a  neatly  applied  flannel  bandage, 
or  a  muslin  bandage  which  has  been  shrunken  by  being 
washed  ;  new  muslin  is  not  satisfactory  as  a  primary  appli- 
cation to  a  limb  in  applying  a  plaster-of-Paris  dressing,  as 
the  moisture  from  the  plaster  wets  it  and  catises  it  to 
shrink,  so  that  it  may  exert  injurious  pressure  after  the 
bandage  becomes  dry. 

TheTlimb  having  been  covered  by  the  bandage,  and  any 


94  BANDAGING. 

bony  prominences,  such  as  the  malleoli,  having  been 
padded  with  small  wads  of  cotton  to  prevent  undue 
pressure  upon  them,  the  part  is  next  covered  by  a  layer 
of  turns  of  a  crinoline  bandage  or  by  strips  of  cheese- 
cloth or  any  other  loose  material.  A  small  quantity  of 
plaster-of-Paris  is  next  mixed  with  water  until  it  has  the 
consistence  of  thick  cream,  when  it  is  smeared  evenly 
over  the  whole  surface  of  the  previously  applied  bandage. 
Another  layer  of  the  bandage  or  of  strips  is  next  applied, 
and  the  plaster  is  smeared  over  this  in  the  same  manner, 
and  so  alternate  layers  of  plaster-of-Paris  and  bandage  are 
applied  until  a  casing  of  the  desired  thickness  is  obtained. 
If  plaster-of-Paris  of  the  quality  previously  described  be 
used,  it  will  set  or  become  hard  in  a  few  minutes. 

The  most  convenient  method  of  applying  the  plaster- 
of-Paris  dressing  is  that  introduced  by  the  late  Professor 
Sayre,  which  consists  in  the  use  of  bandages  which  have 
been  previously  prepared  with  plaster-of-Paris ;  these 
are  moistened  and  applied  while  moist  to  the  part  to  be 
encased. 

Preparation  of  Plaster-of-Paris  Bandages.— These 
bandages  are  prepared  by  taking  cheese-cloth,  mosquito- 
netting,  or  crinoline,  which  latter  is  by  far  the  best 
fabric,  and  cutting  or  tearing  it  into  strips  two  and  a  half 
to  three  inches  in  width  and  five  yards  in  length.  These 
are  laid  on  a  table,  and  plaster-of-Paris  of  the  quality 
before  mentioned  is  dusted  over  them  and  rubbed  into  the 
meshes  of  the  fabric  ;  the  material  when  impregnated  with 
plaster  is  loosely  rolled  into  a  cylinder,  and  these  band- 
ages when  prepared  should  be  placed  in  air-tight  jars  or 
tin  cans  until  required. 

Bandages  thus  prepared,  which  have  been  exposed  to 
the  air  or  have  been  kept  for  a  long  time,  are  not  apt  to 
set  well  when  applied  ;  but  if  such  bandages  are  placed 
in  a  hot  oven  and  baked  for  half  an  hour  before  being 
used,  they  will  be  found  to  set  as  satisfactorily  as  those 
freshly  prepared. 

These  bandages  may  be  prepared  by  a  machine  made 
for  this  purpose;  but  1  do  not  think  that  they  are  apt  to 


FIXED  DRESSINGS,   OR  HARDENING    BANDAGES.     95 

have  the  plaster  as  evenly  distributed  through  them,  and, 
therefore,  are  not  as  satisfactory  as  those  prepared  by 
hand. 

Application  of  the  Plaster-of-Paris  Bandage. — Before 
applying  this  dressing,  the  part  to  be  encased — the  leg,  for 
instance — should  be  covered  by  a  flannel  roller,  the  bony 
prominences  being  protected  by  pads  of  cotton,  or  a 
closely  fitting  stocking  may  be  applied  to  the  part. 

The  bandage  should  be  dipped  in  warm  water  and  kept 
completely  immersed  for  a  few  minutes ;  it  should  then  be 
squeezed  with  the  hand,  and  as  soon  as  bubbles  of  air 
cease  to  escape  it  is  a  sign  that  it  is  thoroughly  soaked 

Fig.  96. 


Leg  encased  in  plaster-of-Paris  dressing. 

and  is  ready  for  application.  On  removing  it  from  the 
water  the  excess  of  water  should  be  squeezed  out  by  the 
hand,  and  the  bandage  should  then  be  applied  evenly  to 
the  limb  with  just  sufficient  firmness  to  make  it  fit  the 
part  nicely,  and  as  few  reverses  as  possible  should  be 
made.  A  sufficient  number  of  bandages  are  applied  to 
make  a  dressing  as  firm  as  may  be  required;  three  rollers 
of  the  above  dimensions  are  usually  ample  for  a  dressing 
for  the  leg,  and  when  the  last  roller  has  been  applied  dry 
plaster  should  be  moistened  with  water  until  it  has  the 
consistency  of  thick  cream,  and  rubbed  evenly  over  the 
surface  of  the  bandage  to  give  it  a  finish  (Fig.  96).  If  a 
good  quality  of  plaster  has  been  used,  the  bandage  should 


96  BAND  A  GTNG. 

be  quite  firm  in  from  ten  to  fifteen  minutes,  but  the  patient 
should  not  for  a  few  hours  be  allowed  to  bear  any  weight 
upon  the  bandage. 

An  equally  firm  bandage  may  be  applied  with  the  use 
of  a  less  number  of  bandages,  if  the  surgeon  rubs  over 
the  surface  of  each  layer  of  bandage  applied  a  little  moist 
plaster,  then  applying  another  layer  and  repeating  the 
procedure  ;  finishing  the  dressing  by  an  external  coating 
of  moist  plaster,  as  above  described. 

In  applying  these  dressings  a  fewer  number  of  band- 
ages will  be  required  if  narrow  strips  of  tin,  zinc,  or 
binders'  board  are  incorporated  in  the  layers  of  the  band- 
age, which  increase  the  strength  of  the  dressing. 

Application  of  the  Plaster-of-Paris  Bandage  to  the 
Thigh    and   Pelvis. — Where  it  is   desirable  to  apply  a 

Fig.  97. 


Pelvic  supporter. 

plaster-of-Paris  bandage  to  the  thigh,  and  at  the  same 
time  fix  the  hip-joint  by  including  the  pelvis  in  the  band- 
age, the  use  of  a  pelvic  supporter  (Fig.  97)  is  most  satis- 
factory. The  patient  is  placed  upon  the  supporter  so  that 
the  lumbar  spine  rests  upon  the  body  of  the  supporter, 
while  the  pelvis  rests  upon  the  metal  shelf  which  extends 
from  it,  as  seen  in  Fig.  98.  The  limb  is  extended  and 
held  in  the  required  position,  and  the  plaster  bandage  is 
applied  to  the  thigh,  and  is  also  carried  around  the  pelvis 
and  passed  over  the  metal  shelf  upon  which  the  pelvis 
rests.  When  the  bandage  has  become  firm,  the  supporter 
is  removed  by  slipping  it  upward. 


FIXED  DRESSINGS,    OR  HARDENING  BANDAGES.      97 

Fig.  98. 


Position  of  patient  upon  pelvic  supporter. 

Interrupted  Plaster-of-Paris  Dressing.— This  form 
of  plaster-of-Paris  dressing  is  applied  by  first  placing  a 
short  iron  rod  under  the  extremity,  opposite  to  and  extend- 
ing some  distance  above  and  below  the  point  at  which  the 

Fig.  99. 


Interrupted  plaster-of-Paris  dressing.    (Stimson.) 

dressing  is  to  be  interrupted  ;  this  is  fixed  by  a  few  turns 
of  the  plaster  bandage  above  and  below  the  portion  of 
the  limb  which  is  to  be  left  exposed  ;  stout  wire  is  next 
bent  into  loops,  the  extremities  of  which  are  incorporated 
in  the  subsequent  turns  of  the  plaster  bandage;  three 
loops  thus  placed  in  addition  to  the  posterior  iron  bar 
will  usually  make  the  dressing  sufficiently  firm  (Fig.  99). 
A  number  of  turns  of  the  bandage  are  applied  to  fix  the 


98  BANDAGING. 

loops  firmly,  and  the  limb  is  held  in  the  desired  position 
until  the  plaster  has  set. 

Application  of  the  Plaster-of-Paris  Jacket. — The 
patient's  body  should  be  covered  with  a  soft,  closely 
fitting  woven  shirt  without  arms,  but  with  shoulder-straps 
to  hold  it  in  position,  or  an  ordinary  woven  undershirt  may 
be  employed  ;  one  or  tAVO  folded  towels,  or  a  pad  of  cotton 
wrapped  in  a  towel,  are  next  placed  over  the  abdomen 
between  the  shirt  and  the  skin — this  was  called,  by  Pro- 
fessor Sayre,  the  dinner  pad,  and  is  intended  to  leave  space 
for  distention  of  the  abdomen  after  eating.  Small  pads 
of  rawr  cotton  may  also  be  placed  over  the  anterior  iliac 
spines,  and,  in  the  case  of  females,  a  pad  of  cotton 
wrapped  in  a  handkerchief  may  be  placed  over  each 
mammary  gland. 

The  patient  should  next  be  suspended  by  the  apparatus, 
consisting  of  a  collar  and  arm-pieces  attached  to  a  cross- 
bar (Fig.  100),  which  is  attached  by  a  cord  and  pulley  to  a 
tripod.  If  this  apparatus  is  not  at  hand,  a  very  satisfac- 
tory substitute  may  be  made  by  folding  two  towels  into 
cravats  and  tying  together  the  ends,  so  as  to  make  two 
loops,  one  of  which  is  placed  in  each  axilla  ;  a  bar  of  wood 
two  and  a  half  feet  in  length  is  next  taken,  and  the  loops 
are  secured  to  the  ends  of  this  by  stout  cords  or  handker- 
chiefs ;  a  Barton's  bandage  is  next  applied  to  the  head,  and 
a  strip  of  bandage  is  passed  under  the  turns  which  cross 
the  vertex  and  is  secured  to  the  middle  of  the  cross-bar. 
The  bar  is  next  suspended  by  a  cord  passed  through  a 
pulley  or  ring,  which  may  be  attached  to  the  top  frame  of 
a  door  if  the  ordinary  tripod  cannot  be  obtained. 

The  patient  should  be  raised  slowly  by  the  apparatus 
until  the  toes  only  are  in  contact  with  the  floor,  and  the  ex- 
tension should  not  be  carried  to  the  point  which  makes  it 
uncomfortable  to  the  patient  (Fig.  101).  The  shirt  should 
be  drawn  downward  over  the  hips  by  an  assistant  and  held 
in  place  until  a  few  turns  of  the  bandage  have  been  applied. 

The  plaster-bandage  having  been  soaked  and  squeezed, 
a  turn  should  be  made  around  the  body  above  the  pelvis, 
and  it  should  then  be  carried  downward  below  the  iliac 


FIXED  DRESSINGS,   OR  HARDENING   BANDAGES.     99 

spines,  and  from  this  point  made  to  ascend  gradually 
by  spiral  turns  until  it  reaches  the  axillary  line.  The 
turns  should  be  applied  smoothly  and  not  too  tightly. 
After  two  or  three  layers  of  turns  have  been  applied,  the 
surgeon  may  rub  some  moist  plaster  upon  their  surface  if 


Fig.  100. 


Fig.  101. 


Suspensory  apparatus. 


Patient  suspended  for  application  of 
plaster  jacket. 


he  desires  to  use  fewer  bandages.  These  turns  are  repeated 
until  a  bandage  of  the  desired  thickness  is  applied,  and  the 
surface  of  the  dressing  may  be  finished  by  rubbing  it  over 
with  moistened  plaster.  This  jacket  for  a  child  will  gen- 
erally require  the  use  of  three  or  four  bandages  of  the 
dimensions  given ;  for  an  adult,  from  six  to  eight  bandages. 


100 


BANDAGING. 


Fig.  102. 


The  patient  should  be  kept  suspended  until  the  bandage 
has  set,  usually  from  ten  to  fifteen  minutes,  and  then  should 
be  lifted  carefully  so  as  not  to  bend  the  spine,  and  placed 
on  his  back  upon  a  mattress,  until  the  dressing  becomes 
perfectly  hardened.  The  dinner  pad  and  mammary  pads, 
if  they  have  been  used,  should  next  be  removed.  In 
applying  this  dressing,  strips  of  zinc  or  tin  may  be  placed 
between  the  layers  of  bandage  if  it  is  desired  to  give  more 
strength  to  the  jacket. 

Application  of  the  Jury-mast  by  Means  of  Plaster- 
of-Paris. — In  disease  of  the  spine  involving  the  cervical 
or  upper  dorsal  region  the  ordinary  plaster-of- Paris  jacket 

is  not  satisfactory,  and  in  such 
cases  the  "  jury-mast "  is  employed 
in  connection  with  the  plaster 
jacket.  In  applying  the  " jury- 
mast,"  the  same  steps  are  taken  in 
the  preparation  of  the  patient  as 
in  applying  the  plaster-of-Paris 
jacket,  with  the  exception  of  ex- 
tension, which  need  not  be  used. 

After  three  or  four  layers  of  the 
plaster-bandage  have  been  applied 
to  the  body,  an  apparatus  made  of 
two  bars  of  metal  having  two  per- 
forated strips  of  zinc  attached  to 
them  a  few  inches  apart,  which 
partly  encircle  the  body,  is  applied 
and  held  in  position  by  turns  of 
the  plaster-bandage.  The  perpen- 
dicular bars  have  at  their  upper 
part  a  slot,  into  which  the  lower 
end  of  the  "jury-mast"  fits,  and 
is  secured  by  a  screw  j  to  the  upper 
part  of  this  is  attached  a  movable 
cross-bar,  to  which  are  fastened  the  straps  of  the  collar 
from  which  the  head  is  suspended  (Fig.  102). 

The  Bavarian  Dressing. — To  apply  this  dressing, 
which  is  sometimes  employed  in  the  treatment  of  fractures 


Head-support  and  jury-mast. 


FIXED  DRESSINGS,   OR  HARDENING  BANDAGES.      101 

of  the  extremities,  take  two  pieces  of  Canton  flannel  the 
length  of  the  part  to  be  enclosed,  and  more  than  wide 
enough  to  envelop  its  circumference.  In  applying  it  to 
the  leg,  these  pieces  should  be  cut  so  as  to  correspond  to 
the  outline  of  the  leg  and  posterior  portion  of  the  foot. 
These  pieces  should  be  placed  one  over  the  other  and 
sewed  together  in  the  middle  line,  the  seam  corresponding 
to  the  back  of  the  leg.  This  dressing  is  then  placed  under 
the  foot  and  leg,  and  the  inner  layer  of  flannel  is  brought 
up  in  front  of  the  leg  and  over  the  dorsum  of  the  foot,  and 
made  fast  with  pins  or  a  few  stitches  (Fig.  103 j.     Plaster- 

Fig.  103. 


Bavarian  dressing. 


of- Paris  is  next  mixed  with  water  to  form  a  paste,  which 
is  rubbed  thickly  and  evenly  over  the  flannel  next  the 
limb  until  a  sufficient  thickness  is  obtained ;  the  outer 
layer  of  flannel  is  then  brought  up  about  the  leg  and 
moulded  to  its  surface  by  the  hands.  A  loosely  applied 
roller  may  be  used  to  hold  the  dressing  in  place  until  the 
plaster  has  set. 

When  it  is  necessary  to  inspect  the  parts,  the  turns  of 
the  bandage  are  cut,  and  upon  separating  the  layers  of 
flannel  the  two  halves  can  be  turned  aside,  the  seam  at  the 
back  acting  as  a  hinge.     Upon .  reapplying  the  splints  to 


102  BANDAGING. 

the  leg  they  may  be  retained  in  position  by  a  roller  or  by 
one  or  two  strips  of  bandage. 

Moulded  Plaster  Splints. — It  is  sometimes  found  diffi- 
cult io  apply  the  ordinary  plaster  dressings  to  parts  irreg- 
ular in  shape,  and  at  the  same  time  to  have  a  splint  which 
can  be  removed  with  ease.  To  accomplish  this  purpose, 
moulded  splints  of  plaster  may  be  made  by  cutting  a 
paper  pattern  of  the  part  to  be  covered  in,  and  then  cutting 
pieces  of  crinoline  to  conform  to  this  pattern  ;  eight  or  ten 
pieces  will  usually  form  a  splint  of  sufficient  thickness. 
One  of  these  pieces  of  crinoline  is  laid  upon  a  table  and 
dry  plaster  is  rubbed  into  its  meshes ;  another  is  laid 
upon  this  and  plaster  is  applied  to  it  in  the  same  way, 
and  so  on  until  all  the  pieces  have  been  placed  in  posi- 
tion, one  over  the  other,  with  plaster  rubbed  well  into 
the  meshes.  The  dressing  is  then  folded  up  and  dipped 
into  water,  squeezed  out,  and  moulded  to  the  part  and  held 
in  position,  until  it  sets,  by  the  turns  of  a  bandage.  The 
edges  should  overlap  slightly,  and  in  applying  it  a  strip  of 
waxed  paper  may  be  placed  under  the  overlapping  edge  to 
prevent  its  adhesion  to  the  dressing  below,  and  thus  facili- 
tate its  removal.  Splints  prepared  in  this  way  can  be  re- 
moved with  ease,  and  are  often  of  service  in  cases  where 
it  is  desirable  to  inspect  the  parts  frequently.  I  have  em- 
ployed with  advantage  such  splints  in  making  fixation  of 
the  hip-joint  in  cases  of  coxalgia,  and  also  for  the  same 
purpose  in  diseases  of  other  joints.  The  splints  upon 
being  reapplied  are  secured  by  a  few  strips  of  adhesive 
plaster  or  by  a  roller-bandage. 

Trapping  Plaster-of-Paris  Bandages. — In  applying 
the  plaster-of-Paris  dressing  to  a  part  where  there  is  a 
wound  which  is  covered  by  the  plaster-bandage,  it  is  well 
to  make  some  provision  whereby  the  plaster  dressing  over 
the  site  of  the  wound  may  be  cut  away,  making  a  trap  or 
window  through  which  the  wound  may  be  inspected,  or 
dressed  if  necessary  (Fig.  104).  To  accomplish  this,  be- 
fore applying  the  plaster-bandage,  a  compress  of  lint  or 
gauze  or  a  small  pasteboard  box  should  be  placed  over 
the  wound,  which,  when  the  dressing  is  completed,  forms 


FIXED  DRESSINGS,   Oil  HARDENING  BANDAGES.      103 

a  projection  on  its  surface,  indicating  the  position  of  the 
wound,  and  also  allows  the  surgeon  to  cut  away  the  dress- 
ing without  injuring  the  skin  below.  These  traps  may  he 
cut  out  after  the  bandage  has  partially  set,  or  after  it  has 
become  hard.  In  applying  the  plaster-of-Paris  dressing 
in  eases  of  compound  fracture,  I  always  make  provision 
for  trapping  of  the  bandage  if  it  should  become  necessary, 
although  in  the  vast  majority  of  cases  if  the  wound  re- 
main aseptic  it  does  not  have  to  be  done. 


Fig.  104. 


Plaster-of-Paris  bandage  trapped.    (Esmarch.) 


Removing  Plaster-of-Paris  from  the  Hands. — One 

objection  to  the  use  of  plaster-of-Paris  dressings  is  the 
difficulty  of  removing  it  from  the  hands  of  the  surgeon, 
and  the  harsh  condition  in  which  the  skin  is  left  after  its 
removal.  If,  however,  the  hands  are  washed  in  a  solu- 
tion of  carbonate  of  sodium — a  tablespoonful  to  a  basin 
of  water — the  plaster  will  readily  be  removed  and  the 
skin  will  be  left  in  a  soft  and  comfortable  condition.  Rub- 
bing the  hands  with  moist  brown  sugar  or  cornmeal 
accomplishes  the  same  object. 

Removal  of  the  Plaster-of-Paris  Bandage. — The 
removal  of  the  plaster-bandage  is  sometimes  a  matter  of 
difficulty,  particularly,  in  the  case  of  fractures,  if  it  has  to 
be  removed  before  the  fragments  below  it  are  consoli- 


104 


BANDAGING. 


dated,  as  it  may  disarrange  them  and  cause  the  patient 
pain  if  it  is  not  accomplished  without  much  force. 

When  the  bandage  is  applied  to  get  a  cast  of  a  part,  or 
in  the  treatment  of  fractures  where  it  may  be  necessary  to 
remove  the  bandage  in  a  few  days  to  inspect  the  parts,  a 
strip  of  sheet-lead  one-half  of  an  inch  in  width  is  first 
placed  over  the  flannel  bandage  and  is  allowed  to  project 
at  each  end  beyond  the  dressing ;  the  plaster  can  then  be 
readily  cut  through  upon  the  strip  of  lead  with  a  knife 
without  injury  to  the  parts  below  (Fig.  105).     As  soon  as 

Fig.  105. 


Cutting  plaster-bandage  upon  lead  strip. 

the  bandage  has  become  firm,  the  lead  strip  is  removed  by 
traction  upon  one  end  of  it;  and,  if  the  bandage  has  been 
entirely  divided,  it  can  be  removed  at  any  time  without 
difficulty. 

In  applying  plaster  dressings  to  the  extremities,  even 
if  their  removal  is  not  likely  to  be  immediately  required, 
I  usually  employ  the  lead  strip,  cutting  the  bandage  upon 
it,  but  leaving  three  or  four  bridges  of  undivided  band- 
age, which  can  easily  be  divided  when  the  removal  of  the 
bandage  is  finally  required. 

Plaster-bandages  may  also  be  removed  by  means  of  a 


FIXED  DRESSINGS,   OR  HARDENING  BANDAGES.     105 

saw  devised  for  this  purpose  (Fig.  106);  hy  Gigli's  wire 
saw  drawn  under  the  bandage  by  a  string,  which  cuts 
rapidly  and  does  not  endanger  the  skin ;  by  strong  cutting- 

Fig.  106. 


Hunter's  saw  for  removing  plaster-bandages. 

shears  of  various  kinds  (Fig.  107) ;  or  a  line  may  be  painted 
over  the  dressing  with  hydrochloric  acid  or  vinegar,  which 
softens  the  plaster,  so  that  it  can  readily  be  cut  through 
with  a  knife.  The  incision  of  the  bandage  upon  the  lead 
strip  or  the  use  of  the  saw  or  shears  is,  I  think,  most 
satisfactory  in   removing  these   dressings.     They  should 

Fig.  107. 


Shears  for  cutting  plaster-bandages. 

be  used  carefully,  as  the  final  layers  of  the  bandage  are 
divided,  to  avoid  wounding  the  skin. 

Uses  of  Plaster-of-Paris  Dressings. — These  dressings 
are  employed  to  secure  fixation  as  primary  or  secondary 
dressings  in  the  treatment  of  fractures,  and  in  the  ambu- 
lant treatment  of  fractures,  and  for  a  like  purpose  in 
injuries  and  diseases  of  the  joints.  They  are  also  largely 
employed  in  the  treatment  of  diseases  and  deformities  of 
the  spinal  column,  and  will  be  found  most  satisfactory 
applications  after  osteotomy  and  tenotomy,  to  secure  im- 
mobility and  to  hold  the  parts  in  their  corrected  positions  ; 
when  employed  in  the  dressing  of  cases  after  tenotomy, 
they  are  generally  used  for  a  few  weeks  until  the  proper 
mechanical  apparatus  is  applied. 


106  BANDAGING. 

The  Starched  Bandage.— To  apply  this  bandage, 
starch  is  first  mixed  with  cold  water  until  a  thin,  creamy 
mixture  results,  and  this  is  heated  until  it  is  converted  into 
a  clear  mucilaginous  liquid.  The  part  to  be  dressed  is  first 
covered  with  a  flannel  roller,  and  over  this  a  few  layers 
of  a  cheese-cloth  or  crinoline  bandage,  which  has  been 
shrunken,  are  applied  j  the  starch  is  then  smeared  or 
rubbed  with  the  hand  evenly  into  the  meshes  of  the  mate- 
rial, and  the  part  is  again  covered  with  a  layer  of  turns 
of  the  bandage,  and  the  starch  is  again  applied ;  this 
manipulation  is  continued  until  a  dressing  of  the  desired 
thickness  is  produced.  Strips  of  pasteboard  may  be 
applied  between  the  layers  of  the  bandage,  to  give  addi- 
tional strength  to  the  dressing,  if  desired. 

It  requires  from  twenty-four  to  thirty-six  hours  for  the 
starched  bandage  to  become  dry  and  thoroughly  set.  It 
may  be  removed  in  the  same  way  in  which  the  plaster-of- 
Paris  dressing  is  removed. 

Use. — Before  the  introduction  of  the  plaster-of-Paris 
dressing,  it  was  frequently  employed  in  the  treatment  of 
fractures,  and  in  injuries  and  diseases  of  the  joints.  It 
may  be  used  in  such  cases,  but  possesses  no  advantage 
over  the  plaster-of-Paris  dressing,  and  has  the  disadvan- 
tage of  setting  much  less  promptly. 

Silicate  of  Potassium  or  Sodium  Bandage. — In 
applying  this  bandage,  after  a  flannel  roller  and  several 
layers  of  a  cheese-cloth  or  crinoline  bandage  have  been 
applied  to  the  part,  the  surface  of  the  latter  is  coated  with 
silicate  of  sodium  or  potassium  applied  by  means  of  a 
brush,  then  a  second  layer  of  bandage  is  applied  and 
treated  in  the  same  manner,  and  this  manipulation  is  con- 
tinued until  a  bandage  of  the  desired  thickness  is  pro- 
duced. This  dressing  .may  also  be  applied  by  soaking 
loosely  wound  rollers  of  crinoline  in  silicate  of  potassium 
or  sodium  and  applying  them  to  the  part  as  the  plaster-of- 
Paris  bandage  is  applied.  It  requires  twenty-four  hours 
for  this  dressing  to  become  firm.  As  it  is  irksome  for  a 
patient  to  keep  a  part  quiet  while  the  silicate  bandage  is 
becoming  firm,  I  often  cover  it  as  soon  as  applied  with  a 


FIXED   DRESSINGS,    OB   HARDENING   BANDAGES.   107 

layer  of  tissue-paper,  and  apply  over  it  a  light  plaster-of- 
Paris  bandage,  which  sets  in  a  few  minutes  ;  this  is  removed 
at  the  end  of  twenty-four  hours,  when  the  silicate  bandage 
is  usually  firm.     In  removing  the  silicate  bandage,  it  may 

first  l>c  softened  by  snaking  it  in  warm  water,  and  then  it 
can  readily  he  cut  with  scissors,  or  it  may  he  cut  with 
bandage-shears. 

In  applying  either  the  starched  bandage  or  the  silicate 
of  potassium  bandage,  care  should  be  taken  to  nse  cheese- 
cloth or  crinoline  which  has  been  shrunken  by  being  moist- 
ened and  allowed  to  dry  before  being  employed ;  other- 
wise, dangerous  compression  of  the  part  may  occur  if 
the  bandage  has  been  firmly  applied  and  shrinks  after  its 
application. 

The  Paraffin-bandage. — Paraffin,  which  melts  at  from 
105°  to  120°  F.,  is  used  in  the  application  of  this  band- 
age. The  limb  bein^  covered  bv  a  flannel  roller,  a  vessel 
containing  paraffin  is  placed  in  a  basin  of  boiling  water. 
As  the  roller,  which  may  be  either  of  flannel,  cheese-cloth, 
or  crinoline,  is  unwound,  it  is  passed  through  the  melted 
paraffin  and  applied  to  the  part,  and  the  turns  are  repeated 
until  a  dressing  of  sufficient  thickness  results,  when  the 
surface  may  be  brushed  over  with  melted  paraffin.  This 
dressing  sets  very  rapidly,  being  quite  firm  in  from  five  to 
ten  minutes. 

Moulded  Splints. 

Raw-hide  or  Leather  Splints. — In  moulding  raw- 
hide or  leather  splints,  it  is  necessary,  first,  to  apply  a 
plaster-of-Paris  bandage  to  the  part  to  which  the  raw- 
hide splint  is  to  be  fitted  ;  and  as  soon  as  the  plaster 
has  set,  it  is  removed,  and  a  solid  plaster  cast  is  next 
made  by  pouring  liquid  plaster-of-Paris  into  this  mould. 
When  this  has  become  dry,  a  piece  of  raw-hide,  which 
has  been  soaked  for  a  time  in  warm  water,  is  moulded 
to  the  cast  and  held  firmly  in  contact  with  it  by  tacks 
or  a  bandage  until  it  has  become  perfectly  dry.  It  is 
then  removed,  and  its  surface  is  covered  with  several 
coats  of  shellac,  to  prevent   its  absorbing  moisture  from 


108 


BANDAGING. 


Fig.  108. 


the  skin  when  applied,  and  changing  its  shape.  Eyelets 
or  hooks  are  fastened  to  the  edges  of  the  splint,  through 
which  tapes  are  passed  to  secure  it  in  place. 

Made  in  this  manner,  raw-hide  splints  fit  the  part  very 
accurately,  and  constitute  a  very  satisfactory  dressing  for 
cases  of  joint-disease,  and  in  the  form  of  leather  jackets 
are  often  employed  in  the  treatment  of  disease  of  the  spine 
in  place  of  the  plaster-of-Paris  jacket  (Fig.  108). 

In  the  treatment  of  high  dorsal  or  cervical  caries  a 
leather  splint  in  two  sections,  which 
rests  upon  the  shoulders  and  sup- 
ports the  head,  is  often  used  with 
good  results  (Fig.  109). 

Binders'  Board  or  Pasteboard 
Splints. — This  material,  which  can 
be  obtained  in  sheets  of  different 
thicknesses,  is  frequently  employed 
for  the  manufacture  of  splints.  In 
moulding  these  splints,  a  portion  of 
the  board  of  the  requisite  size  and 

Fig.  109. 


Leather  jacket  with  jury- 
mast. 


Leather  splint  for  cervical  caries. 
(Owen.) 


thickness  is  dipped  in  boiling  water  for  a  short  time,  and 
when  it  has  become  softened  it  is  removed  and  allowed  to 
cool ;  a  thick  layer  of  cotton-batting  is  next  applied  over 
it,  and  it  is  then  moulded  to  the  part  and  held  firmly  in 


FIXED  DRESSINGS,    OR  HARDENING  BANDAGES.    109 

place  by  the  turns  of  a  roller-bandage ;  in  a  few  hours  it 
becomes  dry  and  hard. 

This  material,  from  its  cheapness  and  the  ease  with  which 
it  is  obtained,  is  frequently  employed  to  mould  splints  for 
the  treatment  of  fractures,  and  for  the  fixation  of  joints  in 
the  treatment  of  acute  and  chronic  joint-affections.  A 
moulded  pasteboard  splint  may  also  be  employed  to  fix  the 
ends  of  the  bones  after  the  excision  of  a  joint. 

Porous  Felt  Splints. — This  material  is  also  employed 
for  the  manufacture  of  splints,  and  is  applied  by  dipping 
the  material  in  hot  water  and  then  moulding  it  to  the  part 
and  securing  it  by  a  bandage  ;  as  it  dries,  it  becomes  hard. 

Hatters'^felt  Splints. — Hatters' -felt  may  also  be  em- 
ployed for  the  manufacture  of  splints  or  dressings.  It  is 
softened  by  dipping  it  in  boiling  water  or  heating  it  in  the 
flame  of  an  alcohol  lamp,  and  when  soft  and  pliable  it  is 
moulded  to  the  part,  and  as  it  cools  it  again  becomes  hard. 
These  splints  are  employed  for  the  same  purpose  as  those 
made  of  plaster-of-Paris,  leather,  or  pasteboard. 


PAKT  II. 

MINOR    SURGERY. 


SURGICAL  BACTERIOLOGY. 

Bacteria  (Schizomycetes). — These  are  minute  cellular 
organisms  of  microscopic  size,  classified  as  belonging  to 
the  vegetable  kingdom,  among  the  fungi.  They  play  an 
active  part  in  the  causation  of  the  processes  of  fermenta- 
tion and  putrefaction,  and  are  the  causal  ^  agents  of  many 
varieties  of  diseases.  The  word  germ  is  often  used  as 
synonymous  with  bacterium  in  speaking  of  the  organisms 
that  cause  disease,  but  we  must  remember  that  certain 
pathogenic  germs,  as  the  hcematozoon  malarice,  the  amoeba 
coli,  and  the  coccidia,  are  members  of  the  animal  king- 
dom and  are  not  bacteria. 

Bacteria  may  be  divided  into  the  lower  and  the  higher 
bacteria.  The  lower  forms  are  always  unicellular,  although 
in  the  process  of  growth  cells  may  remain  attached  to 
each  other ;  while  the  higher  forms  are  filamentous,  often 
branched,  are  made  up  of  numbers  of  simple  cells  joined 
together,  and  the  cells  sometimes  show  a  tendency  to 
specialization.  To  this  class  belong  the  organism  which 
causes  actinomycosis,  the  actinomyces  bovis  seu  hominis, 
and  also  the  streptothrix  madurce,  the  organism  of  Madura 
foot  or  mycetoma.  The  lower  bacteria,  with  which  we  are 
mainly  concerned,  are  unicellular  and  exceedingly  minute, 
the  round  forms  measuring  not  more  than  1  micromilli- 
metre  ("25W0  ^ncn^  m  diameter,  and,  therefore,  only 
capable  of  investigation  under  the  highest  powers  of  the 

ill 


112  MINOR  SURGERY. 

microscope.  When  unstained  they  appear  to  be  homo- 
geneous, but  by  staining  they  can  be  seen  to  possess  a  cell- 
wall  or  limiting  membrane,  not  always  well  defined,  called 
the  ectoderm,  enclosing  the  protoplasmic  contents  or  endo- 
derm,  which  contains  no  nucleus.  The  cell- wall  is  probably 
of  a  gelatinous  nature,  and  when  it  is  well  defined  the  bac- 
teria are  said  to  be  capsulated.  In  the  protoplasm  of  the 
cell-body  certain  bodies,  metachromic  granules,  are  some- 
times seen  by  staining,  as  well  as  other  round  or  oval 
unstained  spaces,  which,  when  situated  at  the  ends  of  a 
bacillus,  are  known  as  polar  granules.  Both  of  these  are 
probably  either  the  results  of  degenerative  changes,  or  are 
artificially  produced  in  drying. 

Certain  bacteria  produce  coloring-matters — red,  yellow, 
and  blue — many  of  which  are  allied  to  the  lipochromes, 
a  class  of  coloring-matters  found  in  certain  animal  and 
vegetable  organisms. 

Unicellular  bacteria  are  classified  according  to  their 
shape  into  cocci,  or  round  cells,  bacilli,  or  rod-shaped 
cells,  and  spirilla,  which  are  cylindrical  cells  of  curved  or 
spiral  outline.  Motility  in  those  bacteria  which  possess  it 
is  due  to  the  presence  of  cilia  or  flagella.  The  ordinary 
mode  of  growth  of  bacteria  is  by  division  or  splitting. 
Under  circumstances  unfavorable  to  growth  they  may 
also  produce  spores,  but  not  as  a  means  of  multiplication, 
as  one  bacterium  usually  produces  but  one  spore. 

Spores. — These  may  be  of  endogenous  or  arthrogenous 
origin.  Endogenous  spores  arise  especially  in  the  bacilli. 
They  appear  in  the  protoplasm  of  the  cell  as  granules, 
which  develop  into  round,  oval,  or  short  rod-shaped 
bodies,  the  remaining  portion  of  the  bacterium  either 
persisting  for  a  time  or  disappearing  very  soon.  Arthro- 
genous spores  appear  to  be  cocci  which  have  swollen, 
become  more  refractive,  and  are  more  resistant  to  unfav- 
orable surroundings  than  the  original  coccus.  Spores  are 
highly  refractive,  and  consist  of  a  protoplasmic  body  with 
a  dense  surround  1112:  membrane.  Thev  are  very  resistant 
to  unfavorable  surroundings,  and  are  much  more  difficult 
to  destroy  by  heat,  chemical  reagents,  or  drying,  than  are 


SURGICAL  BACTERIOLOGY.  113 

adult  bacteria.  When  placed  under  circumstances  favor- 
able to  their  growth,  the  capsule  splits,  and  a  little  bud 
appears  and  develops  into  an  adult  bacterium. 

The  ordinary  method  of  multiplication  of  bacteria  is  by 
division  or  fission,  one  individual  dividing  into  two,  and 
these  again  into  two  more,  the  process  sometimes  taking 
place  with  great  rapidity.  The  new  cells  may  remain 
attached  or  separate,  according  to  the  nature  of  their 
limiting  membrane.  In  the  case  of  cocci,  when  forming 
pairs,  they  are  called  dijAococci.  They  may  also  be  tetra- 
genous,  or  form  chains,  as  in  the  streptococci  and  strepto- 
bacblli ;  or  bunches,  as  in  the  case  of  the  staphylococci. 
A  zobglea  mass  is  formed  by  the  cohesion  of  a  large  num- 
ber of  bacteria,  where,  owing  to  the  gelatinous  nature  of 
their  envelopes,  they  adhere  to  each  other  and  appear  to 
be  imbedded  in  jelly. 

Bacteria  are  found  widely  distributed  in  the  air,  the 
water,  the  earth,  and  wherever  there  is  organic  substance 
from  which  they  can  obtain  their  nutrition.  They  live 
by  breaking  up  into  simpler  forms  the  complex  organic 
compounds  on  which  they  are  dependent  for  their  carbon 
and  nitrogen,  being  unable  to  extract  the  same  from  inor- 
ganic material.  They  also  require  moisture,  being  de- 
stroyed in  time  by  drying.  Those  which  require  oxygen 
are  called  aerobic,  while  those  which  only  grow^  when  it  is 
excluded  are  called  anaerobic.  Facultative  aerobic  and 
facultative  anaerobic  are  terms  used  to  designate  those 
bacteria  which  can  grow  in  its  presence  or  absence  ;  the 
first,  however,  growing  best  with  and  the  latter  best  with- 
out it.  Another  division  of  bacteria  is  into  saprophytic, 
or  those  living  on  dead  organic  matter,  and  parasitic,  or 
those  depending  on  living  organisms,  the  latter  embracing 
the  pathogenic  bacteria.  The  boundary  line  between  these 
two  classes  is  not  well  defined,  however.  A  certain 
amount  of  heat  is  necessary  to  bacterial  existence,  the 
pathogenic  germs  growing  best  at  the  body  temperature ; 
they  are  destroyed  by  high  temperatures,  most  of  the 
pathogenic  bacteria  being  killed  between  122°  and  140° 
F.  (50°  and  60°  C).     The  spores  are,  as  a  rule,  much 

8 


114  MINOR  SURGERY. 

more  resistant  to  heat.  Low  temperatures  tend  to  inhibit 
the  growth  of  bacteria  rather  than  to  destroy  their  life. 
Direct  sunlight  also  has  an  injurious  action  upon  them. 

Cultivation. — Bacteria  are  studied  outside  of  the  body 
by  growing  them  on  culture-media,  which  may  be  liquid 
or  solid,  proteid  or  carbohydrate-containing  material.  The 
media  are  sterilized  and  kept  in  tubes  or  dishes  (Petri's 
dishes).  A  little  of  the  culture  or  material  to  be  studied  is 
transferred  to  the  culture-medium  by  a  sterilized  platinum 
wire  (called  an  bse),  and  spread  on  the  surface  of  the  solid 
medium  (stroke-culture),  or  plunged  into  it  (stab-culture),  or 
mixed  with  the  fluid  medium.  The  tubes  or  plates  are 
then  placed  in  an  oven  heated  to  the  required  temperature. 
The  germs  form  colonies  of  characteristic  size,  shape,  and 
coloring,  and  the  different  species  may  thus  be  isolated  and 
studied.  The  liquid  media  include  bouillon,  peptone  solu- 
tion, and  extracts  of  vegetable  substances,  as  potato.  Solid 
media  include  mixtures  of  beef-extracts  with  gelatin  or 
agar-agar,  coagulated  blood-serum,  and  slices  of  potato  or 
other  vegetables. 

Inoculation. — The  action  of  bacteria  and  their  toxins 
is  studied  experimentally  by  the  injection  of  cultures,  or 
of  the  body  fluids  or  the  juice  of  bacterially  infected  tis- 
sues into  some  of  the  lower  animals.  The  animals  usually 
employed  are  the  guinea-pig,  rabbit,  mouse,  rat,  and 
pigeon.  Injections  are  made  with  a  sterile  hypodermic 
syringe  under  the  skin,  into  the  peritoneal  cavity,  intra- 
venously, and  into  the  anterior  chamber  of  the  eye,  or  the 
skin  may  merely  be  scarified.  The  animal  is  carefully 
watched  afterward,  its  symptoms  noted,  and  when  dead  of 
the  disease,  or  killed,  cultures  are  made  from  the  organs 
and  the  tissue-changes  studied. 

Staining*. — In  order  to  detect  bacteria  in  the  tissues,  or 
to  study  and  differentiate  them  from  each  other,  it  is  neces- 
sary to  stain  them,  and  this  is  accomplished  by  the  use  of 
dilute  aqueous  or  alcoholic  solutions  of  the  aniline  dyes, 
counter-staining  the  tissues  to  make  their  detection  easier. 
Bacteria  differ  widely  in  the  facility  with  which  they  take 
the  stains,  some  staining  readily,  while  others  require  the 


SURGICAL  BACTERIOLOGY.  115 

action  of  heat  or  of  a  mordant ;  and  they  differ  also  in  the 
tenacity  with  which  they  retain  the  stains  in  the  presence 
of  various  reagents,  as  alcohol  and  the  mineral  acids.  AVe 
are  thus  able  to  separate  different  bacteria  by  the  use  of 
special  methods  of  staining  and  decolorizing.  For  exam- 
ple, the  gonococcus,  the  bacillus  coli  communis,  and  the 
typhoid  bacillus  are  decolorized  by  the  use  of  Gram's 
method ;  while  the  bacilli  of  anthrax,  tuberculosis,  diph- 
theria, and  tetanus  are  stained  by  it.  The  aniline  stains 
most  frequently  employed  are  methylene-blue,  gentian- 
violet,  thionin,  fuchsin,  dahlia,  and  vesuvin. 

Koch's  Law. — To  prove  that  a  certain  bacterium  is  the 
cause  of  a  disease,  the  following  rules  have  been  laid  down 
by  Koch  :  The  bacterium  must  first  be  found  in  the  dis- 
eased person  or  animal.  It  must  be  cultivated  outside  of 
the  body.  When  inoculated  in  pure  culture  in  a  healthy 
animal  it  must  produce  the  original  disease.  From  the 
body  of  the  animal  the  original  microbe  must  be  capable 
of  again  being  isolated. 

Intoxication  and  Infection. — Bacteria  usually  gain 
entrance  into  the  body  through  some  break  in  the  conti- 
nuity of  the  skin  or  mucous  membrane,  especially  the  latter, 
owing  to  its  being  easier  of  penetration.  They  often  enter 
through  an  open  wound.  Favoring  elements  are  a  weak- 
ened or  diseased  state  of  health  of  the  individual,  or  an 
unusual  virulence  of  the  germ.  If  the  germs  remain 
localized,  and  only  their  products  are  absorbed,  the  proc- 
ess is  spoken  of  as  intoxication.  If  the  germs  themselves 
enter  the  circulation,  we  have  infection,  although  the  term 
infection  is  used  also  by  surgeons  to  denote  the  presence 
of  bacteria  in  a  wound,  without  necessarily  or  even  usually 
implying  their  presence  in  the  circulation'.  If  the  germ 
be  pyogenic — that  is,  one  that  excites  suppuration — the 
symptoms  produced  by  the  absorption  of  its  products  con- 
stitute saprcemia ;  if  the  germ  enters  the  circulation,  we 
have  septiccemia ;  and  if  it  finds  lodgement  in  the  tissues 
or  organs  and  gives  rise  to  secondary  abscesses,  we  have 
pycemia. 

Elimination. — Bacteria  are  eliminated  by  the  kidneys, 


116  MINOR  SURGERY. 

the  intestine,  the  salivary  glands,  in  the  bile  and  milk,  and 
probably  also  by  the  sweat-glands.  They  frequently  cause 
lesions  in  the  eliminating  organ. 

Pathogenic  Action. — The  pathogenic  action  of  bacteria 
is  due  to  the  formation  of  certain  poisonous  products 
secreted  by  them,  or  produced  by  their  action  upon  the 
tissues.  From  the  bacteria  themselves,  by  their  degen- 
eration, we  have  also  formed  the  proteins.  The  bacteria 
by  their  secretion  produce  the  ferments,  and,  perhaps,  the 
toxins  ;  and  by  their  action  upon  the  tissues  we  have  pro- 
duced the  ptomaines,  amines,  peptones,  albumoses,  fatty 
acids,  etc. 

Toxins. — The  toxins  are  produced  by  the  pathogenic 
bacteria.  They  are  poisonous  when  injected,  even  in  very 
minute  doses,  acting  after  a  period  of  incubation,  and  are 
looked  upon  by  many  observers  as  being  of  the  nature  of 
ferments.  Others  have  classified  them  as  toxalbumins  or 
toxalbumoses.  The  different  pathogenic  bacteria  elaborate 
their  own  specific  toxins.  Some  of  them  have  a  local  as 
well  as  a  general  action,  producing  inflammation,  necrosis, 
etc.,  when  injected  into  living  animals. 

Resistance  of  the  Tissues  to  Bacteria. — That  the 
introduction  of  bacteria  into  the  body  is  not  always  fol- 
lowed by  the  development  of  disease  is  due  to  a  number 
of  circumstances,  one  of  the  most  important  being  the 
resistance  offered  by  the  tissues.  Certain  of  the  leuco- 
cytes have  what  is  known  as  a  jjhagocytic  action — that 
is,  the  pov/er  to  take  into  themselves  and  destroy  by 
intracellular  action  the  invading  germs.  The  leucocytes 
appear  to  be  attracted  to  the  germs  by  a  power  residing 
in  the  bacteria,  known  as  positive  ehemotaxis,  their  migra- 
tion being  accompanied  by  the  nutritive  changes  consti- 
tuting the  process  of  inflammation,  and  in  the  case  of 
pyogenic  germs  of  suppuration.  Inflammation  seems  to 
be  a  limiting  and  protecting  process.  The  bacteria  if  very 
virulent  may  overcome  the  leucocytes,  or  repel  them  by 
the  production  of  toxins,  which  are  negatively  chemotactic 
— that  is,  they  repel  the  leucocytes  and  interfere  with  their 
phagocytic  action,  and  we  have  in  consequence  a  general 


SURGICAL  BACTERIOLOGY.  117 

invasion  of  the  organism  by  the  bacteria,  often  without 
any  local  inflammation,  in  addition  to  the  phagocytic 
action  of  the  leucocytes,  the  blood  and  fluids  of  the  body 
have  a  certain  germicidal  powder,  said  to  be  due  to  the 
presence  of  albuminous  bodies — alexins.  The  presence  in 
a  wound  of  a  foreign  body  favors  the  growth  of  bacteria, 
as  does,  to  a  certain  extent,  the  presence  of  blood-clot  or 
other  material  which  may  act  as  a  culture-medium  for  the 
germs. 

Immunity. — This  consists  in  the  freedom  from  liability 
to  a  disease,  and  may  be  natural  or  acquired.  In  natural 
immunity  the  person  or  animal  is  immune  from  birth ; 
while  acquired  immunity  may  be  the  result  of  a  previous 
attack  of  the  disease  or  may  be  produced  artificially.  As 
examples  of  natural  immunity  we  have  that  shown  by  the 
lower  animals  to  syphilis  and  leprosy,  and  of  man  to  cer- 
tain diseases  of  the  lower  animals.  One  attack  of  small- 
pox, scarlet  fever,  or  typhoid  fever  confers  an  acquired 
immunity  on  the  patient  which  is  usually  permanent; 
while  an  attack  of  pneumonia,  influenza,  or  diphtheria  is 
followed  by  a  period  of  temporary  immunity.  Immunity 
may  also  be  absolute  or  relative ;  the  first  being  rare,  the 
latter  common,  being  overcome  by  unusual  conditions. 
Artificial  immunity  is  active  or  passive.  Active  immunity 
is  obtained  by  the  injection  into  animals  of  increasing 
doses  of  a  pathogenic  organism,  or  of  its  toxins,  the  dose 
being  gradually  increased  until  a  high  degree  of  immunity 
is  obtained.  This  method  is  preventive  of  future  attacks, 
but  owing  to  its  slowness  is  not  useful  against  an  existing 
disease.  Passive  immunity,  which  is  less  lasting  than 
active  immunity,  is  conferred  by  the  injection  into  an 
animal  of  the  serum  of  an  animal  that  has  been  highly 
immunized  by  the  previous  method.  The  serum  will 
destroy  existing  toxins  and  organisms,  and  confer  tem- 
porary immunity  against  further  infection. 

Antitoxin. — The  mechanism  of  the  production  of  im- 
munity is  largely,  if  not  altogether,  dependent  upon  the 
formation,  by  the  reaction  of  the  tissues  to  the  toxins,  of 
an  albuminous  body  known  as  antitoxin.     To  the  presence 


118  MINOR  SURGERY. 

of  this  substance  in  the  serum  of  an  actively  immunized 
animal  is  clue  its  curative  power  when  injected  into  an 
animal  suffering  from  the  same  disease.  The  antitoxin  of 
diphtheria  has  been  widely  employed  of  late  years  with 
beneficial  results,  and  the  investigations  now  being  carried 
on  in  tetanus,  hydrophobia,  anthrax,  and  other  diseases, 
afford  foundation  for  the  hope  that  similar  good  results 
may  be  obtained  with  their  antitoxins.  A  distinction  is 
made  between  antitoxic  serum  and  antimicrobic  serum  : 
the  former  being  produced  by  the  injection  of  toxins,  and 
the  latter  by  the  injection  of  living  bacteria.  The  anti- 
microbic serums  tend  to  the  destruction  or  paralysis  of  the 
micro-organisms,  but  not  necessarily  of  their  toxins. 

Varieties  of  Bacteria. 

The  bacteria  of  importance  surgically  are  those  giving 
rise  to  ordinary  suppuration,  the  gonococcus,  the  tubercle 
bacillus,  the  bacillus  of  malignant  oedema,  of  glanders,  of 
anthrax,  of  tetanus,  of  infectious  emphysema,  and  the 
organisms  causing  actinomycosis  and  mycetoma. 

Bacteria  of  Suppuration. — A  large  number  of  bac- 
teria are  capable  of  giving  rise  to  suppurative  inflam- 
mation, but  the  most  important  are  the  staphylococcus, 
especially  the  staphylococcus  pyogenes  aureus,  and  the 
streptococcus  pyogenes  or  streptococcus  erysipelatis,  they 
being  identical.  Besides  these,  as  rarer  causes,  we  have 
the  bacillus  pyocyaneus,  the  bacillus  coli  communis,  the 
typhoid  bacillus,  the  gonococcus,  the  diplococcus  pneumo- 
niae and  the  bacillus  pneumonias  (Friedliinder). 

Staphylococcus  Pyogenes  Aureus. — This  bacillus,  which 
causes  80  per  cent,  of  suppurative  inflammations,  and  is 
almost  always  the  cause  of  osteomyelitis,  grows  in  clusters 
(Fig.  110),  can  be  cultivated  on  ordinary  media,  but  best 
on  agar,  and  forms  small  round  colonies,  at  first  whitish, 
later  of  an  orange-yellow  color.  It  is  found  in  health  on 
the  skin,  in  the  pharynx,  and  in  the  external  secretions. 

The  staphylococcus  pyogenes  albus,  or  epidermis  albus,  as 
it  is  called,  from  being  found  in  the  epiderm,  is  less  viru- 


SURGICAL  BACTERIOLOGY.  119 

lent  than  the  preceding,  and  forms  white  colonies.     Ji  not 
infrequently  is  the  cause  of  stitch  abscesses. 

Streptococcus  Pyogenes.  —This  is  a  small  round  organ- 
ism which  forms  chains  (Fig.  111).  It  is  found  occasion- 
ally on  mucous  surfaces  in  health,  and  causes  dangerous 

Fig.  110.  Fig.  111. 

°0    cu         o&o  ooO°0 


0\ 
JO 


*    --  oo„     * 


W 


Jo 


Staphylococcus  pyogenes  aureus.  Streptococcus  pyogenes. 

(Abbott.)  (Abbott.) 

phlegmonous  inflammations.     It   also   causes   erysipelas, 
being  identical  with  the  streptococcus  erysipelatis. 

Bacillus  Coli  Communis. — This  is  a  rod-shaped  bacillus, 
and  may  be  long  and  slender  or  short  and  rounded.  It 
strongly  resembles  the  typhoid  bacillus.  It  is  provided 
with  flagella.  It  is  found  in  the  intestines  in  health,  and 
seems  to  acquire  virulent  properties  from  inflammation 
or  strangulation  of  the  bowel,  giving  rise  to  appendicitis 
and  peritonitis  by  migration  through  the  diseased  wall  of 
the  bowel  or  by  escape  through  a  rupture ;  it  may  also  be 
the  cause  of  cystitis,  pyelitis,  pyelo- 
nephritis, and  occasionally  of  local-  FlG- 112- 
ized  abscesses.  ^f% 

Gonococcus. — This,    the   germ   of  ^g^    j$*Mm 

gonorrhoea,  is  a  kidney -shaped  coccus, 
arranged  in  pairs,  with  the  concave 
edges  toward  each  other ;  the  diplo- 
cocci    usually  inhabit  the    pus-cells,  |pl 

but  are    Occasionally  free    (Fig.   112).      Gonococcus.  (After  Bumm.) 

Besides  specific  urethritis;  it  causes 

salpingitis,   oophoritis,   arthritis,    endocarditis,    conjuncti- 
vitis, proctitis,  and  other  lesions. 

Tubercle  Bacillus. — This,  the  cause  of  tuberculosis,  is  a 
rod-shaped  bacillus,  sometimes  slightly  curved,  1.5  to  3.5 
micromillimetres  in  length  and  0.2  to  6.5  micromillimetre 


120 


MINOR  SURGERY. 


thick.  It  is  not  motile,  and  occurs  singly,  in  pairs,  and 
in  groups ;  spore-production  has  not  as  yet  been  demon- 
strated (Fig.  113).  Inoculation  may  be  directly  through 
a  wound,  or  by  inhalation,  ingestion,  or  placental  trans- 


9/h/.M 


Tubercle  bacilli.    (Abbott.) 


mission,  the  last  being  rare.  It  may  infect  any  organ  of 
the  body.  It  causes  tuberculosis  in  many  of  the  lower 
animals,  cattle  being  especially  liable  to  its  infection. 

Bacillus  Mallei. — Glanders  is  caused  by  this  bacillus, 
which  resembles  the  tubercle  bacillus,  but  is  shorter  and 


Fig.  114. 


Fig.  115. 


•, 


A£ 


V 


Bacillus  mallei.    (Abbott.) 


Threads  of  bacillus  anthracis  con- 
taining spores.    (Abbott.) 


thicker  (Fig.  114).     Infection  of  the  mucous  membranes 
of  the  respiratory  tract  and  through  the  skin  is  not  un- 


SURGICAL  BACTERIOLOGY.  121 

common  in  men  who  are  exposed  to  infection  from 
horses. 

Bacillus  Anthracis. — This,  the  cause  of  anthrax,  is  a 
very  large,  straight  bacillus,  usually  from  5  to  20  micro- 
millimetres  in  length,  sometimes,  however,  attaining  a 
length  of  50  micromillimetres.  It  forms  long  chains  and 
produces  spores,  which  are  very  resistant  (Fig.  115). 
Infection  in  man  usually  arises  from  handling  infected 
skins  and  hides,  and  causes  a  local  inflammation,  with 
general  septicaemia.  Infection  may  also  take  place  through 
the  lungs  or  through  the  gastro-intestinal  tract. 

Bacillus  of  Tetanus. — This  is  a  rod-shaped  organism 
which,  owing  to  the  formation  of  a  spore  at  one  end  which 

Fig.  116.  Fig.  117. 


/>  o     *f° 


0 


6        \  V    ° 

Tetanus  bacillus.     (Abbott.)  Bacillus  of  malignant  oedema, 

spore  stage.    (Abbott.) 

distends  it,  is  often  of  a  drumstick  shape  (Fig.  116).  It 
is  anaerobic,  being  found  especially  in  garden-earth,  in 
the  excrement  of  animals,  and  around  stables.  Infection 
follows  wounds,  especially  punctured  wounds  by  nails  or 
splinters,  which  are  liable  to  be  contaminated  from  the 
earth  ;  infection  is  also  quite  common  in  puerperal  women 
and  in  the  newborn.  Suppuration  in  a  wound  favors 
its  development.  The  bacterium  apparently  remains 
localized,  producing  its  characteristic  symptoms  by  the 
action  of  very  powerful  toxins,  of  which  two,  tetanin  and 
tetanotoxin,  have  been  isolated.  An  antitoxin  has  been 
isolated  from  immunized  animals,  and  good  results  have 
been  reported  from  its  administration  in  individuals  suffer- 
ing from  tetanus,  but  it  has  often  proved  disappointing. 
Bacillus    of    Malignant    (Edema. —This   resembles    the 


122  MINOR  SURGERY. 

anthrax  bacillus  in  appearance,  being  more  slender,  how- 
ever, and,  like  it,  has  a  tendency  to  form  chains.  It  is 
motile,  being  provided  with  flagella,  is  anaerobic,  and 
forms  spores  (Fig.  117).  It  occurs  in  the  soil,  in  dust, 
and  in  the  contents  of  the  intestines  of  lower  animals.  In 
the  lower  animals  it  is  the  cause  of  the  disease  known  as 
malignant  oedema,  which  is  associated  with  suppuration 
and  necrosis  of  the  subcutaneous  tissues,  emphysema,  and 
gangrene.  In  man  it  has  been  found  in  certain  cases  of 
rapidly  spreading  traumatic  gangrene  and  gangrenous 
emphysema,  arising  in  connection  with  compound  fract- 
ures and  other  deep  punctured  wounds. 

Bacillus  Aerogenes  Capsulatus. — This  organism  is  from 
3  to  6  micromillimetres  in  length,  and  may  be  found 
singly,  clumped,  or  in  chains.  It  is  non-motile,  anaerobic, 
and  does  not  form  spores.  It  finds  entrance  into  the  body 
through  a  wound  or  ulceration,  external  or  internal,  and 
its  effects  resemble  somewhat  those  produced  by  the 
bacillus  of  malignant  oedema,  viz.,  necrosis,  gangrene,  and 
the  production  of  gas,  which  in  this  case  is  found  in  any 
or  all  of  the  tissues  and  organs  and  in  the  blood,  in  the 
form  of  minute  bubbles,  in  the  walls  of  which  the  bacilli 
may  be  found.  In  man  it  produces  the  condition  which 
has  been  described  as  gaseous  gangrene,  infectious  emphy- 
sema, gas  phlegmon,  and  emphysematous  necrosis. 

Actinomyces,  or  Ray  Fungus. — This  organism  probably 
belongs  to  the  higher  order  of  bacteria,  and  occurs  in 
yellow  masses,  which  may  be  visible  to  the  naked  eye. 
The  masses  consist  of  organisms  with  diverging  rays, 
consisting  of  threads  with  bulbous  ends  (Fig.  118).  It 
occurs  rarely  in  man,  commonly  in  the  lower  animals, 
from  which  it  has  been  obtained  in  pure  culture.  When 
implanted  in  the  tissues,  to  which  it  is  conveyed  through 
a  wound  or  carious  tooth,  sometimes  apparently  in  seeds 
or  in  grains,  it  excites  a  chronic  inflammation,  with  the 
presence  of  granulation-tissue,  necrosis,  and  suppuration. 
In  man  it  occurs  most  frequently  in  the  mouth,  tongue, 
and  internal  organs.  In  cattle  it  affects  the  jaws,  causing 
"  lumpy  jaw." 


THEORY  OF  ASEPSIS  AND  ANTISEPSIS.         12:} 


Fig.  118. 


Actinomyces.    (Baoigartex.) 

Mycetoma,  or  the  Streptothrix  Madurae. — This  is  a 
branching  micro-organism,  resembling  the  actinomyces, 
and,  like  it,  occurring  in  granular  masses  composed  of 
branching  threads.  It  causes  in  the  foot  especially,  the 
formation  of  nodular  masses,  which  break  down  and  form 
abscesses  and  fistulae,  and  often  produces  caries  and  necrosis 
of  the  bones. 


THEORY    OF  ASEPSIS  AND  ANTISEPSIS    IN    WOUND 

TREATMENT. 


Before  the  introduction  of  Lister's  method  of  treat- 
ing wounds,  it  was  the  rule  in  accidental  and  operative 
wounds  to  have  profuse  suppuration,  fever,  pain,  and  in 
many  cases  such  wound  complications  as  septicaemia, 
pyaemia,  erysipelas,  and  hospital  gangrene,  and  the  mor- 
tality following  operative  and  accidental  wounds  was  very 
high.  The  mortality  in  compound  fractures  from  sepsis 
was  formerly  great,  but  by  modern  methods  of  wound 
treatment  has  been  diminished  to  an  insignificant  percent- 
age. The  same  diminished  mortality  has  followed  ampu- 
tations and  other  wounds,  accidental  or  operative. 

Lister's  method  of  wound  treatment  was  largely  based 


124  MINOR  SURGERY. 

upon  the  idea  that  the  infection  of  the  wound  occurred 
from  contact  with  the  air,  which  contained  spores  and 
germs,  and  his  method  of  treatment  was  chiefly  directed 
to  their  destruction.  The  air  may  be  a  medium  of  wound 
infection  to  a  certain  extent,  for  it  has  been  demonstrated 
that  dry  air  contains  dust  in  which  spores  and  bacteria 
are  present  in  much  larger  numbers  than  in  moist  air,  and 
such  air  coming  in  contact  with  an  open  wound  deposits 
there  numbers  of  bacteria,  which  may  set  up  inflammatory 
changes.  Koch  later  demonstrated  the  fact  that  atmos- 
pheric microbes  were  chiefly  of  an  innocuous  character, 
and  that  wound  infection  was  generally  caused  by  bacteria 
or  spores  being  brought  in  direct  contact  with  the  wound 
by  the  clothing  and  skin  of  the  patient,  the  instruments 
and  the  hands  of  the  surgeon  and  assistants,  and  unclean 
surgical  dressings. 

Cheyne  has  shown  that  the  relative  number  of  bacteria 
entering  the  tissues  is  an  important  factor  in  producing 
suppuration  and  septic  infection,  for  we  know  that  bacte- 
ria may  exist  in  an  aseptic  wound  and  yet  the  wound  heal 
and  remain  aseptic,  the  antiseptic  qualities  of  the  blood- 
serum  and  the  cell-activity  in  healthy  tissues  being  suffi- 
cient to  destroy  or  remove  a  certain  number  of  micro- 
organisms, and  suppuration  or  septic  infection  occurring 
only  when  the  tissues  are  overwhelmed  by  the  number  of 
organisms  or  when  their  power  of  resistance  is  diminished 
by  injury  or  disease.  This  explains  the  satisfactory  be- 
havior of  wounds  which  pursue  an  aseptic  course  where 
very  imperfect  details  of  aseptic  or  antiseptic  treatment 
have  been  employed.  It  may,  therefore,  be  assumed  that 
infection  does  not  necessarily  depend  upon  the  presence  of 
a  few  microbes,  but  rather  upon  the  quantity  and  quality 
of  the  germs  which  are  present  in  the  wound. 

Pyogenic  micro-organisms  under  different  conditions 
may  produce  a  series  of  different  diseases,  for  it  is  now 
generally  accepted  that  Fehlei sen's  streptococcus  erysipe- 
latis  is  identical  with  streptococcus  pyogenes,  which  is  recog- 
nized as  the  cause  of  very  different  inflammatory  affec- 
tions.    The  theory  has  been  advanced  by  Reger  that  all 


THEORY  OF  ASEPSIS  AND  ANTISEPSIS.  125 

the  so-called  pus-diseases  are  simply  local  expressions 
of  a  general  infection  caused  by  many  different  micro- 
organisms. . 

Sepsis.— Sepsis  is  due  to  the  entrance  and   multiplica- 
tion of  micro-organisms,  or  the  absorption  of  their  products 
in  the  body,  and  is  characterized  by  local  inflammation  of 
the  wound,  and  marked  constitutional  symptoms,  such  as 
fever,  disorders  of  the  nervous  system,  and  inflammation 
of  the  viscera.     Microbic  infection  represents  a  patholog- 
ical process  which  causes  serious  wound  complications,  and 
differs  materially  from  that  process  which  attends  the  re- 
pair of  wounds  that  run  an  aseptic  course.     Aseptic  chem- 
ical irritation  of  the  tissues  mav  result  in  the  production 
of  a  puruloid  fluid,  which  is  not  pus,  but  merely  a  fibrinous 
exudation  containing  numerous  cells,  and  does  not  produce 
infection  if  injected  into  animals.     Acute  suppuration  in  a 
wound  is  considered  clinically  to  be  always  due  to  the 
presence  of  bacteria,  for  their  exclusion  will  prevent  its 

occurrence.  .         .    . 

Asepsis.— Asepsis  aims  at  thorough  sterilization  ot  the 
field  of  operation  and  of  all  objects  brought  in  contact  with 
the  wound,  and  the  exclusion  of  micro-organisms  by  oc- 
clusive sterilized  dressings.  >       m  ■ 

Antisepsis,  on  the  other  hand,  has  in  view  the  destruc- 
tion of  micro-organisms  by  keeping  germicidal  agents  con- 
stantly in  contact  with  the  wound.  The  object  of  anti- 
sepsis is,  therefore,  to  produce  asepsis. 

No  surgeon  should  undertake  the  performance  ot  an 
operation  or  the  treatment  of  an  open  wound  without  hav- 
ing: clearly  impressed  upon  his  mind  the  important  part 
that  pyogenic  and  specific  micro-organisms  may  play  in  the 
subsequent  course  of  the  wound. 

Methods  of  Disinfection  or  Sterilization. 

Since  the  majority  of  wound  complications  are  due  to 
the  presence  in  the  wound  of  micro-organisms  it  is  the 
duty  of  the  surgeon  to  prevent  their  contact  with  it,  or  to 
employ  means  for  their  destruction.     We  must,  however, 


126  MINOR  SURGERY. 

employ  means  of  disinfection  or  destruction  of  these  micro- 
organisms which  will  not  have  any  injurious  effect  upon 
the  tissues  with  which  they  come  in  contact.  Mechanical 
disinfection  or  sterilization,  is  not  applicable  to  wounds,  but 
is  employed  to  remove  any  micro-organisms  which  may  be 
present  upon  the  objects  which  are  to  come  in  contact  with 
the  wound;  namely,  the  hands  of  the  surgeons  and  assist- 
ants, instruments,  and  the  skin  surrounding  the  wound. 
Mechanical  disinfection  is  accomplished  by  the  use  of  fric- 
tion with  a  brush,  soap,  and  water.  Germicidal  solutions 
may  be  used  for  disinfection  of  wounds,  but  are  most  use- 
ful in  the  disinfection  of  the  hands  of  the  operator,  the  skin 
of  the  patient,  the  instruments,  and  the  dressings.  If  these 
have  been  carefully  employed  before  the  wound  is  made, 
their  subsequent  use  in  the  wound  is  usually  unnecessary. 

Some  forms  of  bacilli  contain  spores  which  resist  the 
action  of  germicidal  substances,  while  the  bacilli  them- 
selves are  readily  destroyed  by  these  agents  :  the  surgeon 
should,  therefore,  employ  that  means  of  disinfection  which 
is  generally  applicable  to  the  destruction  of  both  bacilli 
and  their  spores.  The  bacilli  of  anthrax,  tuberculosis,  and 
tetanus  contain  spores ;  hence  to  destroy  these  organisms 
is  a  matter  of  more  difficulty  than  to  render  harmless  such 
micro-organisms  as  staphylococcus  "pyogenes  aureus,  albus, 
and  citreus,  streptococcus  pyogenes  and  streptococcus  erysip- 
elatis,  and  the  bacilli  of  diphtheria  and  glanders,  which 
contain  no  spores. 

Heat  when  used  as  a  germicide  cannot  be  applied  to  the 
wound  itself,  except  in  cases  where  a  limited  surface  of 
the  wound  may  be  touched  with  the  hot  iron.  Heat  can, 
therefore,  be  used  only  for  the  disinfection  of  substances 
coming  in  contact  with  the  wound,  and  for  this  purpose  it 
is  employed  in  the  form  of  steam,  dry  heat,  or  boiling  water. 

Sterilization  of  the  wound  or  the  substances  coming  in 
contact  with  it  may  be  accomplished  by  using  either  the 
aseptic  method  or  the  antiseptic  method,  and  at  the  present 
time  these  two  methods  are  to  a  certain  extent  combined — 
that  is,  it  is  impossible  to  be  strictly  aseptic  without  em- 
ploying means  of  disinfection  by  the  use  of  antiseptics. 


THEORY  OF  ASEPSIS  AM)   ANTISEPSIS.  \27 

The  aseptic  method,  which  employs  germicidal  substances 
only  for  the  purpose  of  sterilization  of  objects  coming  in  con- 
tact with  the  wound  when  their  disinfection  by  heat  is  im- 
possible, is  the  method  which  has  generally  been  adopted. 

Antiseptic  Method. — In  the  antiseptic  method  the 
sterilization  of  the  field  of  operation,  the  hands  of  the 
surgeon  and  assistants,  the  instruments,  ligatures,  sponges, 
and  sutures,  is  accomplished  by  the  use  of  germicidal 
solutions,  and,  in  addition,  the  wound  is  irrigated  fre- 
quently during  the  operation  with  germicidal  solutions, 
and  is  afterward  covered  with  dressings  impregnated  with 
germicidal  substances.  The  antiseptic  method  was  that 
first  employed,  and,  recognizing  its  value  in  surgical  pro- 
cedures, many  surgeons  still  continue  to  employ  this 
method  ;  but  it  has  certain  disadvantages.  Recent  inves- 
tigations have  shown  that  many  germicidal  substances 
have  not  the  power  which  was  formerly  attributed  to 
them,  as  they  only  arrest  bacterial  development ;  many 
chemical  germicides  cause  the  formation  of  a  dense  layer 
of  coagulated  albumin  around  albuminous  substances,  and 
also  fail  to  destroy  micro-organisms  associated  with  fatty 
or  oily  substances.  Chemical  germicides  may  also  form 
combinations  in  the  tissues  with  substances  with  which 
they  come  in  contact,  seriously  impairing  their  germicidal 
action.  Antiseptic  substances  which  are  active  as  germi- 
cides often  cause  irritation  of  the  surface  of  the  wound, 
interfering  with  its  repair. 

It  has  been  shown  that  irrigation  of  a  fresh  wound  with 
a  1  :  10,000  solution  of  bichloride  of  mercury  is  followed 
by  distinct  evidence  of  superficial  necrosis  of  the  tissues. 
Antiseptic  irrigation  of  wounds  is  apt  to  cause  very  free 
oozing  of  serum,  which  necessitates  the  use  of  drainage, 
and  makes  frequent  dressing  of  the  wound  necessary. 
Many  antiseptic  substances  produce  marked  toxic  effects 
upon  the  patient,  and  also  cause  severe  irritation  of  the 
skin  with  which  they  come  in  contact. 

Aseptic  Method. — In  employing  the  aseptic  method 
in  the  treatment  of  wounds,  the  field  of  operation,  the 
hands  of  the  surgeon  and  assistants,  the  instruments,  liga- 


128  MINOR  SURGERY. 

tures,  sponges,  and  sutures,  are  sterilized  by  the  use  of 
germicidal  solutions  and  heat,  and  after  this  has  been 
accomplished,  relying  upon  the  completeness  of  the  steril- 
ization, no  germicidal  substances  are  brought  in  contact 
with  the  wound,  sterilized  water  or  sterilized  salt  solution 
being  used  if  it  is  necessary  to  Hush  the  wound,  and  the 
dressings  employed  are  those  only  which  have  been  ster- 
ilized by  moist  or  dry  heat.  The  advantages  of  the 
aseptic  method  are  as  follows  :  the  method  is  applicable  to 
all  parts  of  the  body  ;  wounds  treated  by  this  method  heal 
more  promptly  and  do  not  require  frequent  dressing  ;  there 
is  no  risk  of  toxic  effects,  and  there  is  no  irritation  of  the 
skin  by  the  dressings.  Dry  sterilized  dressings  are  effi- 
cient to  produce  absorption,  and  at  the  same  time  the 
dryness  may  be  a  factor  in  the  destruction  of  germs, 
for  depriving  bacteria  of  moisture  robs  them  of  one  of 
the  conditions  necessary  to  their  existence.  The  aseptic 
method  is,  therefore,  to  be  preferred  to  the  antiseptic 
method  in  the  treatment  of  wounds  wherever  it  is  possible. 

Agents  Employed  to  Secure  Asepsis. 

A  great  variety  of  agents  possessing  more  or  less 
germicidal  properties  have  been  at  different  times  em- 
ployed in  the  practice  of  aseptic  or  antiseptic  surgery ; 
those  most  employed  at  the  present  time  are  heat,  bichlo- 
ride of  mercury,  carbolic  acid,  iodoform,  formalin,  beta- 
naphthol,  formaldehyde,  chloride  of  zinc,  acetate  of 
aluminum,. peroxide  of  hydrogen,  kreolin,  permanganate 
of  potassium,  sulphorarbolate  of  zinc,  salicylic  and  boric 
acids,  acetanilid,  aristol,  and  certain  silver  salts. 

Heat. — The  most  reliable  and  universally  available 
agent  for  the  destruction  of  micro-organisms  is  heat,  either 
dry  or  moist ;  many  forms  of  bacteria  are  rendered  inert 
at  a  temperature  of  140°  F.,  and  none  can  withstand  the 
application  of  moist  heat  at  21 2°  F.  continued  for  a  short 
time.  Spores  which  will  resist  the  action  of  powerful 
germicides  for  a  considerable  time  are  destroyed  by  boil- 
ing for  a  few  minutes.     Dry  heat  is  not  as  efficient  for 


BICHLORIDE  OF  MERCURY. 


129 


Fig.  119. 


sterilization  as  moist  heat,  for  some  spores  will  resist  dry 
heat  of  284°  F.  for  three  hours.  As  moist  heat  is  the 
most  efficient  sterilizer,  it  should  be  preferred,  and  can 
always  be  made  use  of  for  this  purpose  by  boiling  the 
instruments  and  dressings  for  a  few  minutes  ;  and  if  for 
any  reason  it  is  thought  advisable  to  employ  dry  heat  as 
a  sterilizer,  this  may  be  made  use  of  by  baking  the  instru- 
ments or  dressings  in  a  hot  oven.  The  best  results  may 
be  obtained  by  the  use  of  one  of  the  various  dry  or  moist 
sterilizers  (-Fig.  119).  An 
improvised  sterilizer  may  be 
made  by  placing  a  perforated 
metal  stand  inside  a  large 
kettle,  so  that  only  the  steam 
comes  in  contact  with  the 
instruments  and  dressings. 

Bichloride  of  Mercury. 
— This  is  employed  as  an 
antiseptic  in  watery  solu- 
tions varying  in  strength 
from   1  :  500  to  1 :  10,000. 

The  solution  of  1  :  500  to 
1  :  1000  is  used  only  for  the 
irrigation  and  disinfection  of 
the  hands  and  skin  ;  for  the 

irrigation  of  wounds,  a  solution  of  1  :  '2000  or  1  :  4000 
may  be  employed.  At  the  present  time  bichloride  solu- 
tions are  not  frequently  used  in  fresh  wounds,  on  account 
of  their  irritating  effects.  Where  continuous  irrigation  is 
kept  up,  or  where  it  is  employed  in  large  cavities,  a  still 
weaker  solution,  1  :  5000  to  1  :  10,000,  should  be  employed. 

In  using  bichloride  solutions  the  surgeon  should  watch 
the  patient  carefully  for  signs  of  poisoning  due  to  absorp- 
tion of  the  bichloride  of  mercury  ;  the  symptoms  denoting 
this  are  vomiting,  fetid  breath,  salivation,  inflammation 
of  the  gums,  diarrhoea,  blood-stained  stools,  and  bleeding 
from  the  mouth  and  nose.  Locally  the  use  of  moist  bi- 
chloride dressings  may  cause  well-marked  dermatitis.  The 
continuous  application  of  bichloride  solution  to  the  hands 

9 


Steam  sterilizer. 


130  MINOR  SURGERY. 

of  the  surgeon  causes  the  skin  to  become  roughened  and 
blackens  the  nails. 

In  preparing  solutions  of  bichloride  of  mercury  for  use, 
it  will  be  found  convenient  to  have  a  concentrated  solu- 
tion of  the  salt  in  alcohol,  1  part  of  the  bichloride  to  10 
parts  of  alcohol ;  this  can  be  kept  in  a  well-stoppered 
bottle,  and  to  it  should  be  added  one  teaspoonful  of  com- 
mon salt,  which  prevents  disintegration  of  the  mercuric 
compound.  One  teaspoonful  of  this  solution  added  to  one 
quart  of  water  makes  a  1  :  2500  solution. 

A  10  per  cent,  bichloride  solution  may  be  made  as  fol- 
lows : 

Bichloride  of  mercury 2  parts. 

Sodium  chloride 1  part. 

Dilute  acetic  acid 1     " 

Aquse  dest 16  parts. 

By  adding  water  in  an  appropriate  quantity,  a  1 :  1000  or  1 :  2000 
solution  can  be  made. 

Or  the  solution  may  be  prepared  with  tartaric  acid  in 
the  proportion  of  5  parts  of  the  acid  to  1  part  of  bi- 
chloride of  mercury,  the  following  formula  being  em- 
ployed : 

Hydrarg.  chlor.  corrosiv grs.  xv. 

Ac.  tartaric grs.  lxxv 

Aqua?  dest Oij. 

Pellets  containing  a  definite  amount  of  bichloride  of 
mercury  compounded  with  a  few  grains  of  common  salt  of 
muriate  of  ammonium,  which,  when  dissolved  in  a  definite 
quantity  of  water,  make  a  solution  of  1  :  1000  or  1  :  2000, 
will  also  be  found  very  convenient  for  the  preparation  of 
solutions.  The  pellets  should  also  contain  a  little  coloring- 
matter,  which  gives  a  faint  color  to  the  solution  and  serves 
to  distinguish  it  from  other  solutions. 

Carbolic  Acid. — This  drug  is  employed  in  solutions  of 
1  :  20  or  1  :  40.  The  stronger  solution,  1  :  20,  is  usually 
employed  to  sterilize  instruments,  the  latter  being  allowed 
to  remain  in  this  solution  for  thirty  minutes  before  being: 


used.     As  a  carbolic  solution  of  this  strength   benumbs 
and  cracks  the  skin  of  the  hands  of  the  operator,  it  should 


IODOFORM.  13] 

be  diluted  just  before  the  instruments  are  required,  by 
adding  an  equal  quantity  of  boiled  water,  making  it  a 
1  :  40  solution.  The  rusting  of  steel  instruments  and  the 
dulling  of  the  edges  of  knives  by  exposure  to  carbolic 
aeid  may  be  prevented  by  the  addition  of  5  per  cent,  of 
sodium  carbonate  to  the  solution. 

The  1  :  40  or  1  :  60  solution  is  used  for  the  irrigation  of 
wounds  and  the  washing  of  sponges.  As  carbolic  acid  in 
strong  solutions  is  a  local  caustic  and  coagulates  albumin, 
it  should  not  be  used  in  fresh  wounds.  A  ready  method 
of  making  a  5  per  cent,  carbolic  solution  is  to  add  one 
tablespoon ful  of  carbolic  acid  to  one  pint  of  hot  water. 

In  using  carbolic  acid  solutions  continuously,  the  sur- 
geon should  be  on  the  watch  for  symptoms  of  poisoning, 
which  will  be  manifested  by  dark-colored  urine,  head- 
ache, dizziness,  vomiting,  and  in  severe  cases  bloody  diar- 
rhoea, hemoglobinuria,  and  death  from  collapse.  Carbolic 
acid  solutions  should  be  used  with  great  caution  in  young 
children,  as  they  seem  to  be  more  susceptible  than  adults 
to  its  constitutional  effects. 

The  use  of  weak  solutions  of  carbolic  acid  seems  to 
involve  more  risk  of  toxic  action  than  does  the  employ- 
ment of  the  pure  drug,  the  superficial  layer  of  tissue  being 
coagulated  by  the  latter,  so  that  absorption  of  the  drug 
is  prevented.  Gangrene  of  the  skin  and  subjacent  tissues 
has  frequently  been  observed  to  follow  long-continued  use 
of  quite  dilute  solutions  of  carbolic  acid  or  of  ointments 
containing  small  quantities  of  the  drug.  Cases  of  gan- 
grene of  the  fingers  and  toes  from  this  cause  are  not  infre- 
quently seen. 

Iodoform. — Iodoform  has  been  shown  by  experimental 
research  to  possess  little  direct  germicidal  action,  but  in 
spite  of  this  fact  clinical  experience  has  proved  that  it 
possesses  powerful  antiseptic  properties,  due,  as  shown  by 
Behring  and  De  Ruyter,  not  to  the  destruction  of  germs. 
but  to  its  undergoing  decomposition  in  their  presence, 
and  thus  rendering  inert  the  ptomaines  which  have  re- 
sulted from  the  germ-growth.  It  may  be  rendered  abso- 
lutely sterile  by  exposing  it  to  heat,  and,  as  it  is  easily 


132  MINOR  SURGERY. 

decomposed,  fractional  sterilization  may  be  employed,  or 
by  washing  it  in  a  1  :  1000  bichloride  solution  ;  it  should 
then  be  dried  and  kept  for  use  in  closely  stoppered  bottles. 
Iodoform  is  often  employed  in  the  form  of  a  powder  as  an 
application  to  wounds,  and  is  frequently  used  in  aseptic 
wounds  which  are  liable  from  their  position  to  become  in- 
fected, such  as  those  about  the  mouth,  rectum,  and  vagina, 
and  is  especially  useful  as  a  dressing  in  infected  wounds 
and  in  tubercular  or  syphilitic  ulcers  and  in  bone  cavities. 
In  operations  upon  the  mouth,  anus,  rectum,  uterus,  and 
abdominal  cavity  iodoform  gauze  packing  is  largely  em- 
ployed, and  serves  to  keep  the  discharges  from  becoming 
foul,  thus  often  preventing  septic  intoxication ;  it  must, 
however,  be  used  with  caution  in  the  mouth.  Iodoform 
collodion,  made  by  adding  iodoform,  gr.  xlviii,  to  col- 
lodion, f§j,  is  a  useful  dressing  in  superficial  wounds. 
Iodoform  may  also  be  employed  in  the  form  of  an  ethereal 
solution,  iodoform,  gr.  xv ;  ether,  fjj,  as  an  application 
to  wounds  or  ulcers.  An  emulsion  of  iodoform  in  glyc- 
erin, iodoform,  3j  ;  sterilized  glycerin,  ,5x,  or  an  emul- 
sion of  iodoform  made  by  adding  sterilized  iodoform,  3J, 
to  boiled  olive  oil,  gx,  is  much  employed  as  an  injection 
in  the  treatment  of  tubercular  abscesses  and  joints.  For 
packing  cavities,  a  5  per  cent,  gauze  is  best ;  a  10  per  cent, 
gauze  is  too  strong  except  in  small  amounts.  For  large 
cavities  a  Mikulicz  pack,  consisting  of  a  bag  of  iodoform 
gauze  stuffed  with  sterilized  gauze,  may  be  employed. 

Numerous  cases  have  been  reported  in  which  toxic  symp- 
toms have  followed  the  use  of  iodoform,  such  as  urtica- 
rial eruptions,  dermatitis,  headache,  depression,  delirium, 
mania,  debility,  and  sleeplessness.  Elderly  persons  and  in- 
fants are  very  susceptible  to  the  toxic  action  of  iodoform. 

Airol. — This  drug  has  been  used  as  a  substitute  for 
iodoform  where  an  antiseptic  and  not  an  antitubercular 
action  was  desired.  It  seems  to  be  free  from  toxic  action 
even  when  used  in  large  quantities.  It  is  especially  useful 
in  wounds  where  primary  infection  is  present.  It  has  been 
used  with  good  results  in  operations  upon  the  rectum  and 
bladder. 


FORMALIN.  133 

Formaldehyde. — This  is  a  pungent,  penetrating  gas, 
possessing  valuable  antiseptic  properties,  which  is  prin- 
cipally used  for  the  disinfection   of  clothing,  instruments, 

bedding,  and  rooms.  The  gas  is  generated  in  a  lamp  or 
generator  by  passing  the  vapor  of  methyl  alcohol  over  a 
coil  of  glowing  platinum  wire  or  gauze,  or  over  platinized 
asbestos. 

Formalin. — This  is  a  40  per  cent,  solution  of  formal- 
dehyde gas  in  water,  and  has  valuable  antiseptic  proper- 
ties. A  solution  of  this  strength  is  a  powerful  irritant,  and 
should  not  be  used  in  the  treatment  of  wounds.  It  may 
be  used  in  a  2  per  cent,  solution  to  disinfect  wounds  or 
instruments,  or  in  0.25  per  cent,  solution  for  irrigation. 
Brewer  recommends  a  1  per  cent,  solution  applied  for  three 
minutes  to  disinfect  the  skin,  a  2  per  cent,  solution,  applied 
under  anaesthesia,  to  sterilize  infected  tissues,  and  0.3  per 
cent,  solution  for  gauze. 

Formalin-gelatin  or  Glutol. — This  is  a  compound 
formed  by  evaporating  an  aqueous  solution  of  gelatin 
over  vapor  of  formalin.  Its  activity  as  an  antiseptic  de- 
pends upon  the  vapor  of  formalin  given  off  when  applied  to 
the  wound.   It  is  a  non-irritating  and  non-poisonous  powder. 

Beta-naphthol. — Beta-naphthol,  in  a  1  :  2500  solution, 
is  employed  for  much  the  same  purposes  as  bichloride  of 
mercury  solutions  ;  it  is  not,  however,  so  powerful  a  germi- 
cide. It  is  employed  in  irrigating  large  cavities,  because 
it  is  not  a  poisonous  agent,  and  is  especially  useful  as  a 
bath  for  instruments,  as  it  does  not  corrode  them,  as  do 
sublimate  solutions.  It  may  be  employed  as  a  dusting- 
powder  on  sloughing  surfaces,  and  especially  to  wounds 
exposed  to  feces  or  urine.  It  also  possesses  the  advantage 
over  a  carbolic  acid  solution  of  not  irritating  the  skin  of 
the  surgeon's  hands. 

Silver  Salts. — Silver  lactate  (actol)  and  silver  citrate 
(itrol)  are  two  antiseptics  which  have  been  recommended 
by  Crede,  who  considers  their  germicidal  properties  supe- 
rior to  those  of  bichloride  of  mercury.  These  salts  may  be 
used  in  a  1  :  4000  or  1  :  8000  solution,  which  should  be 
made  with  water  free  from  chlorides,  which  precipitate  the 


134  MINOR  SURGERY. 

silver  ;  distilled  water  should  be  employed.  Creole  speaks 
highly  of  an  ointment  made  of  metallic  silver,  which  may 
be  employed  as  an  inunction  in  septic  diseases. 

Acetanilid. — This  preparation  possesses  antiseptic;  prop- 
erties, and  is  frequently  used  as  a  substitute  for  iodoform. 
It  may  be  used  in  the  form  of  powder  as  an  application  to 
suppurating  or  ulcerating  tissues,  but  in  tubercular  condi- 
tions is  not  as  satisfactory  as  iodoform. 

Chloride  of  Zinc. — Chloride  of  zinc,  in  a  solution  of 
30  to  40  grains  to  water  fsj,  is  a  very  powerful  antiseptic. 
When  employed  upon  raw  surfaces  it  produces  marked 
blanching  of  the  tissues ;  it  is  especially  useful  in  wounds 
which  are  infected  or  which  have  been  exposed  to  infec- 
tion. I  have  found  it  by  all  means  the  best  application 
for  the  poisoned  wounds  which  are  received  in  dissect- 
ing dead  bodies  and  in  operating.  In  such  cases  the 
whole  cavity  or  surface  of  the  wound  should  be  washed 
with  a  30-grain  solution,  and  then  the  wound  should  be 
dressed  with  moist  bichloride  gauze. 

Sulphocarbolate  of  Zinc. — This  drug  has  been  found 
to  possess  more  decided  antiseptic  properties  than  the  chlo- 
ride of  zinc,  and  is  much  less  irritating.  It  may  be  used 
in  the  same  strength  and  for  the  same  purposes  as  the 
latter  drug. 

Acetate  of  Aluminum. — This  drug  is  used  in  solution, 
and  is  prepared  as  follows  :  aluminis,  3vj  (24  grammes) ; 
plumbi  acetatis,  sixss  (38  grammes)  ;  aqua?,  Oij  (1000 
grammes).  Mix,  and  filter  after  standing  twenty-four 
hours.  It  has  decided  germicidal  qualities,  is  employed  for 
irrigation  and  moist  dressing  where  carbolic  or  bichloride 
solutions  cannot  be  used,  and  is  by  all  means  the  safest 
and  best  antiseptic  substance  for  wet  dressings. 

Peroxide  of  Hydrogen. — Peroxide  of  hydrogen  is  em- 
ployed in  what  is  known  as  the  15- volume  solution.  It 
may  be  used  in  this  strength  or  may  be  diluted.  It  seems 
to  have  a  direct  action  upon  pus-generation  by  destroying 
the  micro-organisms  of  pus,  and  is  frequently  employed  in 
the  sterilization  of  sinuses  or  suppurating  cavities,  such  as 
remain  after  the  opening  of  abscesses  or  result  from  dis- 


BORIC  ACID.  135 

eases  of  or  operation-  upon  the  bones.  It  is  injected  into 
the  sinuses  and  cavities  by  means  of  a  glass  syringe,  or 
may  be  applied  to  open  wounds  in  the  form  of  a  spray. 
Its  action  is  shown  by  the  escape  of  bubbles  of  gas,  which 
cleanse  suppurating  surfaces  or  sinuses  mechanically,  and 
it  should  be  used  as  long  as  these  continue  to  escape. 

Pyrozone. — Pyrozone  possesses  the  same  qualities  as  the 
peroxide  of  hydrogen,  and  apparently  to  a  somewhat  higher 
degree,  and  is  used  for  the  same  purposes. 

Kreolin. — This  substance  is  obtained  from  English  coal 
by  dry  distillation,  and  has  been  found  to  possess  powerful 
germicidal  properties ;  it  is  non-irritating  and  practically 
non-toxic.  It  is  insoluble  in  water,  but  forms  an  emul- 
sion with  it  which  possesses  marked  antiseptic  properties. 
It  is  especially  useful  as  a  deodorant  in  oifensive  malig- 
nant ulcers.  It  may  be  employed  for  the  same  purposes 
as  carbolic  acid.  It  is  used  in  an  emulsion,  in  strength 
from  2  to  5  per  cent.,  and  is  employed  in  the  irrigation 
of  large  wounds  or  cavities  of  the  body,  and  has  been 
most  favorably  recommended  in  gynecological  practice. 

Boric  Acid. — This  drug  has  not  very  marked  antiseptic 
qualities,  and  is  usually  unirritating  even  in  saturated 
solutions;  but  occasionally  it  produces  marked  irritation 
of  the  skin.  It  is  frequently  employed  in  a  5  per  cent, 
solution  to  cleanse  and  disinfect  mucous  surfaces  and  large 
cavities.  It  is  often  employed  to  wash  out  the  bladder 
before  the  operation  for  the  removal  of  calculi  or  growths 
from  that  organ.  In  the  dressing  of  superficial  wounds, 
or  in  wounds  in  which  the  bichloride  or  carbolic  acid 
dressings  produce  irritation,  an  ointment  of  boric  acid.  1 
part,  to  petrolatum  5  parts,  will  be  found  very  satisfactory. 

Boro-salicylic  Powder. — This  powder,  winch  consists 
of  4  parts  of  boric  acid  to  1  part  of  salicylic  acid,  is  used 
as  a  dusting-powder  and  as  a  dressing  for  wounds.  It  has 
been  recommended  highly  by  Senn  in  the  treatment  of 
fresh  wounds. 

Salicylic  Acid. — Salicylic  acid  does  not  have  very 
marked  antiseptic  qualities,  but  possesses  much  less  toxic 
action  than  carbolic  acid,  and  is   used  for  somewhat  the 


136  MINOR  SURGERY. 

same  purposes.  Its  antiseptic  power  is  said  to  be  increased 
by  the  addition  of  boric  acid,  and  a  boro-salicylic  lotion 
(Thiersch's  solution)  is  prepared  by  adding  salicylic  acid, 
1  part;  boric  acid,  6  parts;  to  hot  water,  500  parts,  mak- 
ing a  bland  solution,  which,  when  reduced  to  25  to  50  per 
cent,  of  the  original  strength,  may  be  used  for  irrigation 
of  the  bladder  or  the  peritoneal  cavity. 

Permanganate  of  Potassium. — This  drug,  owing  to  its 
rapid  absorption  of  oxygen,  acts  as  an  antiseptic,  and  is 
often  employed  for  the  disinfection  of  foul  wounds  and 
ulcers.  It  is  employed  also  in  solution  for  washing  the 
operator's  hands  and  for  the  washing  of  sponges.  It  is 
practically  non-irritating,  and  may  be  used  in  quite  con- 
centrated solutions,  but  is  usually  employed  in  the  follow- 
ing strength  :  permanganate  of  potassium,  gj  ;  water,  f^j. 
One  fluidrachm  of  this  solution  to  a  pint  of  water  makes 
a  1  :  1000  solution. 

Aristol. — Aristol,  which  is  a  compound  of  iodine  and 
thymol,  possesses  germicidal  properties,  and  has  been  in- 
troduced as  a  substitute  for  iodoform.  It  has  the  advan- 
tage over  iodoform  of  not  being  poisonous,  and  is  also 
without  disagreeable  odor.  It  may  be  employed  for  the 
same  purposes  as  iodoform,  and  it  seems  to  be  particularly 
useful  as  a  dressing  to  chronic  and  specific  ulcers. 

Orthoform. — This  is  a  colorless  powder  which  is  slightly 
soluble  in  water.  It  possesses  decided  antiseptic  properties 
as  well  as  a  local  anaesthetic  action.  It  is  employed  as  a 
dressing  for  small  wounds,  burns,  and  ulcers.  As  it  pos- 
sesses toxic  action,  it  should  not  be  used  where  there  is  an 
extensive  raw  surface. 

Sodium  Chloride. — This  salt  has  no  direct  antiseptic 
action,  but  is  used  in  the  preparation  of  normal  salt  or 
saline  solution,  the  strength  of  which  is  0.6  per  cent. 

Saline  Solution. — This  is  prepared  by  adding  6  drachms 
of  sterilized  sodium  chloride  to  1  litre  of  distilled  water, 
which  is  contained  in  a  sterilized  oval  glass  flask.  The 
mouth  of  the  flask  should  be  plugged  with  sterilized  cotton, 
and  a  piece  of  gauze  fastened  over  the  mouth  and  neck  of 
the  bottle.     The  solution  should  be  exposed  to  steam  ster- 


MATERIALS   USED  IN  ASEPTIC  OPERATIONS.    137 

ilization  one-half  hour  on  two  successive  clays.  Saline 
solution  is  non-irritating,  and  is  frequently  used  in  the  irri- 
gation of  fresh  wounds,  to  remove  foreign  bodies  or  blood, 
and  for  the  cleansing  of  mucous  and  serous  surfaces.  Its 
utility  by  intravenous  injection  or  infusion  is  well  recog- 
nized (see  page  199).  In  emergencies  a  solution  prepared 
by  adding  a  drachm  of  common  salt  to  a  pint  of  water 
which  has  been  sterilized  by  boiling,  may  be  employed. 

Sterilization  of  Water. — Water  may  be  rendered  abso- 
lutely sterile  by  boiling  from  fifteen  to  thirty  minutes.  It 
should  be  distilled  or  filtered  before  being  boiled,  to  re- 
move any  inert  matter  which  is  not  desirable  in  wounds. 
After  being  boiled,  it  should  be  placed  in  sterilized  glass 
flasks,  and  corked  with  sterilized  cotton,  the  mouths  of  the 
flasks  also  being  covered  with  several  layers  of  gauze. 
It  is  employed  for  the  irrigation  of  wounds  and  of  mucous 
and  serous  surfaces. 


PREPARATION  OF  MATERIALS  USED  IN  ASEPTIC 

OPERATIONS. 

Sponges. — Marine  sponges  are  the  best  materials  for 
the  purpose  of  sponging,  but  their  satisfactory  sterilization 
is  often  a  matter  of  difficulty.  It  is  better  to  use  a  cheap 
grade  of  sponges,  and  to  use  them  only  once.  The  steril- 
ization of  sponges  by  boiling  destroys  to  a  certain  extent 
their  elasticity  and  their  absorbent  power.  Elsberg  claims 
that  sponges  can  be  boiled  in  the  following  solution  with- 
out losing  their  properties  :  caustic  potash,  1  per  cent. ; 
tannic  acid,  2  per  cent. ;  water,  97  per  cent.  Schimmel- 
busch  recommends  the  following  method  :  The  dried 
sponges  are  freed  from  dirt  or  sand  by  beating,  and  are 
then  soaked  for  several  days  in  cold  water  slightly  acidu- 
lated with  hydrochloric  acid,  being  kneaded  from  time  to 
time.  They  are  next  thoroughly  washed  in  cold  and  in 
warm  water,  wrapped  in  a  linen  sheet,  and  placed  in  a 
boiling  1  per  cent,  soda  solution  ;  the  solution  should  not 
be  allowed  to  boil  after  the  sponges  are  placed  in  it.    They 


138  M1X0R  SURGERY. 

are  allowed  to  remain  in  this  hot  solution  for  thirty  min- 
utes, are  then  washed  in  boiled  water  to  remove  the  soda, 
and  placed  in  a  0.5  per  cent,  bichloride  solution  until 
needed. 

Another  method  of  preparing  sponges  consists  in  beat- 
ing them  to  remove  any  sandy  matter  which  they  may 
contain,  and  placing  them  for  twenty-four  hours  in  a  solu- 
tion of  hydrochloric  acid,  4  ounces ;  water,  4  pints ;  upon 
removing  them  from  this  solution  they  are  washed  until 
free  from  acid  ;  they  are  then  placed  for  ten  minutes  in  the 
following  solution  :  potassium  permanganate,  £ij  ;  sodium 
sulphate,  gj  ;  hydrochloric  acid,  lij  ;  distilled  water,  Oij. 
They  are  then  removed  and  placed  in  running  water  for 
six  hours,  and  afterward  in  a  5  per  cent,  carbolic  acid 
solution  or  a  1  :  1000  bichloride  solution.  Carbolic  solu- 
tion is  the  better  one,  as  it  is  not  so  liable  to  decomposition. 

Gauze  Pledgets  or  Pads. — On  account  of  the  difficulty 
in  satisfactorily  sterilizing  sponges,  as  well  as  of  their 
expense,  folded  gauze  pledgets  have  largely  superseded 
them. 

Gauze  Pledgets. — Gauze  pledgets  are  prepared  by  cutting 
a  piece  of  gauze,  composed  of  from  twelve  to  sixteen  layers, 
in  pieces  six  inches  square;  the  four  angles  of  these  pieces 
are  then  tied  together  or  secured  by  a  few  stitches. 

Gauze  Pads, — Gauze  pads  are  made  from  a  piece  of  gauze 
composed  of  from  sixteen  to  twenty  layers  cut  the  desired 
size,  the  different  layers  in  each  pad  being  quilted  together 
by  a  few  stitches,  and  the  edges  loosely  whipped  with  a 
thread  to  prevent  them  from  fraying.  Gauze  pads  are 
used  as  a  substitute  for  the  flat  sponges  formerly  employed 
in  abdominal  surgery,  and  for  the  drying  of  wounds.  The 
pads  or  pledgets  may  be  sterilized  by  boiling  or  by  expos- 
ure to  steam  or  dry  heat  in  a  sterilizer,  or  may  be  steril- 
ized and  preserved  at  the  same  time  in  a  1  :  2000  bichloride 
solution.  When  so  preserved,  before  being  employed  the 
moisture  should  be  squeezed  from  them,  and  they  should 
be  washed  in  sterilized  water  before  being  brought  in 
contact  with  the  wound. 

Silk  Sutures  and   Ligatures. — Silk  for  sutures  or 


MATERIALS   USED  IN  ASEPTIC  OPERATIONS.   139 

ligatures,  either  the  plaited  silk  or  the  Chinese  twisted 
silk,  should  be  sterilized  by  boiling   from   ten   to  thirty 
minutes  in  a  5  per  cent,   solution   of  carbolic  acid,  or  in 
water,  the  time  of  boiling  depending  upon  the  thickness 
of  the  threads ;  frequent"  boiling  renders  the  silk  weak. 
It  should  then  be  placed  in  stoppered  bottles  and  covered 
with  a  5  per  cent,  solution  of  carbolic  acid  or  with  abso- 
lute alcohol,  or  in  1:1000  bichloride  and  alcohol  solution. 
Silkworm- gut. — Silkworm  gut  is  an  excellent  material 
for  sutures,  and  may  be  sterilized  by  boiling  it  for  fifteen 
minutes,  or  by  placing  it  for  one-half  hour  in  a  5  per 
cent,  carbolic  solution ;  after  being  sterilized,  it  should  be 
kept  in  95  per  cent,  alcohol.     There  has  recently  been 
introduced  an  iron-dyed  black  silkworm-gut,  which  makes 
the    sutures    more    prominent    and  thus  facilitates    their 

removal.  . 

Catgut  Ligatures  and  Sutures.— Catgut  is  the  ideal 
material  for  ligatures  and  sutures,  but  has  the  disadvan- 
tages of  difficulty  and  uncertainty  in  its  sterilization. 
Raw  catgut  is  often  infected  with  micro-organisms,  and, 
therefore,  thorough  sterilization  alone  can  render  it  a  safe 
material  for  ligatures  and  sutures. 

Von  Bergmann's  Catgut.— This  method  of  preparing 
catgut,  which  we  have  found  one  of  the  most  satisfactory, 
consists  in  winding  the  catgut  loosely  upon  glass  rods  or 
spools;  these  spools  are  placed  in  ether  for  twenty-four 
hours ;  the  ether  is  then  poured  off,  and  they  are  placed  in 
the  following  solution  :  bichloride  of  mercury,  10  parts ; 
absolute  alcohol,  800  parts ;  distilled  water,  200  parts 
Remove  from  this  solution  after  twenty-four  hours,  and 
place  them  in  a  similar  solution  for  forty-eight  hours  ;  then 
place  in  absolute  alcohol.  If  soft  catgut  is  desired,  add 
20  per  cent,  of  glycerin  to  the  absolute  alcohol.  To 
make  the  sterilization  absolutely  certain,  it  has  been  found 
advantageous  to  soak  the  catgut  for  thirty  minutes  in  a 
1:1000  aqueous  bichloride  solution  before  placing  it  in 
the  alcoholic  solution  of  bichloride. 

Dry  Sterilized  Catgut. — Boeckrnan's  process  for  steriliz- 
ing catgut  consists  in  cutting  .the  gut  in  pieces  twenty  to 


140  MINOR  SURGERY. 

forty  inches  in  length,  wrapping  each  piece  in  paraffin- 
paper  and  sealing  in  a  paper  envelope.  The  envelopes  are 
then  placed  in  a  steam  sterilizer  for  three  hours  at  a  tem- 
perature of  284°  F.,  and  then  for  four  hours  longer  at  a 
temperature  of  290°  F.  When  required  for  use,  the  en- 
velope is  opened,  the  paraffin-paper  removed,  and  the  gut 
immersed  for  a  few  minutes  only  in  sterilized  water. 

Boiled  Catgut. — Catgut  may  also  be  sterilized  by  boil- 
ing in  alcohol  under  pressure.  The  most  satisfactory 
method  is  that  devised  by  Fowler,  which  consists  in  plac- 
ing a  number  of  strands  of  catgut  in  an  ordinary  test-tube 
which  is  filled  with  95  per  cent,  alcohol  to  within  half  an 
inch  of  the  top ;  a  wad  of  cotton  is  next  pushed  into  the 
mouth  of  the  tube,  and  a  cork  is  introduced.  The  tubes 
thus  prepared  are  placed  inverted  in  a  fruit-jar  filled  with 
95  per  cent,  alcohol ;  the  jar  is  then  closed  and  placed  in 
a  water-bath,  and  kept  at  a  boiling  temperature  for  an 
hour.  Or  the  catgut  may  be  loosely  wound  upon  glass 
rods  and  spools,  and  placed  in  a  metallic  cylinder  or  jar 
having  an  accurately  fitting  screw-top.  The  catgut  is 
then  covered  with  absolute  alcohol,  the  top  is  screwed 
down,  and  the  cylinder  or  jar  is  immersed  in  boiling 
water  for  an  hour. 

Formalin  Catgut. — This  is  prepared  by  winding  catgut 
loosely  on  glass  spools  and  keeping  them  for  forty-eight 
hours  in  a  vessel  containing  equal  parts  of  alcohol  and 
ether.  They  should  next  be  washed  for  a  few  minutes  in 
alcohol  and  placed  in  a  jar  containing  equal  parts  of 
alcohol  and  formalin,  and  allowed  to  remain  for  several 
days.  The  excess  of  formalin  should  then  be  washed 
away  with  alcohol,  and  the  catgut  kept  for  use  in  95  per 
cent,  alcohol. 

Cumol  Catgut. — The  catgut  is  rolled  loosely  on  glass 
spools,  which  are  placed  in  a  glass  beaker  having  a  layer 
of  cotton  in  the  bottom  ;  the  beaker  is  covered  by  a  piece 
of  cardboard  having  a  hole  in  the  centre  through  which  a 
thermometer  is  introduced,  and  is  placed  on  a  sand-bath 
heated  by  a  Bunsen  burner.  Heat  is  applied  until  the 
temperature  is  raised  to  176°  F. ;  this  is  maintained  for 


MATERIALS   USED   IN  ASEPTIC  OPERATIONS   141 

one  hour,  and  removes  all  moisture  from  the  catgut. 
Cumol,  at  a  temperature  of  212°  F.,  is  next  poured  into 
the  beaker,  completely  covering  the  catgut,  and  the  tem- 
perature is  then  raised  to  329c  F.  and  maintained  for  one 
hour.  The  cumol  is  next  poured  off,  and  the  catgut  is 
allowed  to  dry  in  the  beaker  on  the  sand-bath  at  a  tem- 
perature of  ^12°  F.  for  two  hours;  it  is  then  transferred 

sterile  jars  or  tubes,  which  should  be  air-tight. 

Elsberg's  Method  of  Sterilizing  Catgut. — The  catgut  is 
immersed  for  forty-eight  hours  in  a  mixture  of  1  part 
of  chloroform  to  2  part-  of  alcohol,  then  wound  Loosely 
upon  spools  and  boiled  for  thirty  minutes  in  a  saturated 
solution  of  ammonium  sulphate,  and  upon  its  removal 
from  this  solution  it  should  be  immersed  in  sterilized 
water  to  remove  crystals  of  ammonium  sulphate.  It  may 
then  be  preserved  in  absolute  alcohol. 

Bichloride  of  Palladium  Catgut. — The  catgut  should  be 
soaked  in  ether  from  twenty-four  to  forty-eight  hours, 
according  to  the  size  of  the  gut.  It  is  then  placed  in  a 
mixture  of  mercuric  bichloride,  -40  grains  ;  tartaric  acid, 
200  grains;  alcohol  (95  per  cent.),  12  fluidonnces,  and 
allowed  to  remain  from  five  to  twenty-live  minutes,  ac- 
cording to  the  size  of  the  gut.  Then  place  it  in  a  ster- 
ilized jar  containing  palladium  bichloride  grain  -^  to 
alcohol  1  pint,  in  which  it  may  be  kept  indefinitely. 

Chromic  Acid  or  Chromicized  Catgut. — Catgut,  after 
being  soaked  in  ether  for  twenty-four  hours  and  washed 
in  alcohol,  is  placed  for  twenty-four  hours  in  a  4  per  cent, 
aqueous  solution  of  chromic  acid  ;  it  is  then  removed  and 
dried  in  a  hot  oven,  and  placed  in  closely  stoppered  jars, 
or  may  be  preserved  in  absolute  alcohol.  Catgut  thus 
prepared  will  resist  the  action  of  living  tissues  for  several 
weeks,  the  time  of  its  absorption  depending  upon  the  size 
of  the  gut.  Before  being  used,  it  should  be  sterilized  by 
either  the  cumol,  alcohol,  or  formalin  method. 

Owing  to  the  fact  that  it  undergoes  very  slow  solution 
in  the  tissues,  chromicized  catgut  is  often  employed  for 
sutures  or  for  the  ligation  of  the  larger  vessels  in  their 
continuitv,  and  for  bone  sutures. 


142  MINOR  SURGERY. 

A  very  simple  method  of  carrying  catgut  and  keeping 
it  sterile  consists  in  using  a  strong  glass  tube,  about  an 
inch  in  diameter  and  six  inches  in  length,  into  each  end 
of  which  is  fastened  a  rubber  cork.  A  number  of  glass 
spools  wound  with  sterilized  catgut  of  various  sizes  are 
fitted  into  this  glass  tube,  and  one  cork  is  introduced  ;  the 
tube  is  then  filled  with  alcohol  or  a  1  :  2000  bichloride 
solution  in  alcohol,  and  the  other  cork  is  introduced,  or  a 
test-tube  and  a  rubber  stopper  may  be  used. 

Celluloid.  Thread. — This  material,  recently  introduced 
by  Pagenstecher,  is  prepared  by  boiling  linen  thread  for 
thirty  minutes  in  a  1  per  cent,  solution  of  sodium  carbonate. 
It  is  then  dried  between  sterile  compresses  and  soaked  for 
some  hours  in  celluloid  solution.  It  may  be  kept  dry  or 
in  an  alcoholic  solution  of  bichloride  of  mercury.  It  may 
be  resterilized  by  boiling  or  under  steam  pressure.  It  has 
proved  a  satisfactory  material  for  sutures  and  ligatures, 
and  may  be  used  in  place  of  catgut  or  silk. 

Drainage-tubes. — The  drainage-tubes  usually  employed 
are  prepared  from  rubber-tubing  of  different  sizes  perfor- 
ated at  short  intervals ;  the  black-rubber  tubes  are  softer 
and  more  pliable  than  the  red-  or  white-rubber  tubes,  and 
are  generally  preferred  (Fig.  120).  Drainage-tubes  are  also 
made  of  glass,  straight  or  curved  (Fig.  121),  which  are 
almost  exclusively  used  in  abdominal  surgery,  and  also  of 
decalcified  bone.  The  tubes  should  be  kept  in  a  5  per 
cent,  solution  of  carbolic  acid,  or,  if  kept  dry,  they  should 
be  well  washed  and  sterilized  by  boiling  water  for  a  few 
minutes  before  being  used. 

Catgut  and  Horsehair  Drainage. — Catgut  as  ordi- 
narily prepared  for  ligatures  may  be  used  to  secure  drain- 
age in  small  and  superficial  wounds ;  a  number  of  strands 
are  placed  in  the  bottom  of  the  wound,  and  the  ends  are 
allowed  to  project  from  one  or  both  extremities  of  the 
wound. 

Horsehair  may  be  employed  for  the  same  purpose,  a 
number  of  strands  of  the  hair  being  placed  in  the  wound 
in  the  same  manner.  Before  being  used,  it  should  be  well 
washed  with  soap  and  water,  and  then  soaked  in  a  5  per 


MATERIALS    USED  IX  ASEPTIC   OPERATIONS.    143 


cent,  carbolic  solution  or  1  :  1000  bichloride  solution  for 

thirty  minutes. 

Fig.  1-20.  Fir;.  121. 


Eubber  drainage-tube. 


Glass  drainage-tube. 


Protective. — Protective  is  employed  to  prevent  the 
wound  from  being  irritated  by  the  antiseptic  substances 
with  which  the  gauze  is  impregnated  or  by  its  irregular 
surface.  The  great  objection  to  the  use  of  protective  is 
that  it  sometimes  interferes  with  drainage,  and  permits  of 
the  accumulation  of  serum  beneath  it,  which  mav  become 
infected  and  cause  infection  of  the  wound. 

Various  materials  are  employed  as  protectives,  the  prin- 
cipal requirement  being  that  they  can  readily  be  rendered 
aseptic  and  do  not  absorb  irritating  materials  from  the 
dressings. 

The  protective  first  employed  by  Mr.  Lister,  which  is 
still  generally  used,  is  prepared  by  coating  oiled  silk  with 
copal  varnish,  and  when  this  is  dry  a  mixture  of  1  part  of 
dextrin,   2  parts  of   powdered  starch,  and  16  parts  of  a 


144  MINOR  SURGERY. 

1  :  20  carbolic  acid  solution,  is  brushed  over  its  surface. 
Rubber-tissue  may  be  employed  very  satisfactorily  as  a 
substitute  for  this  protective. 

Before  applying  the  protective  to  the  wound,  it  is 
soaked  in  a  solution  of  bichloride  of  mercury  or  carbolic 
acid. 

Silver  Foil. — The  inhibit! ve  action  of  metallic  silver  on 
the  growth  of  micro-organisms  is  utilized  in  the  employ- 
ment of  silver  foil  to  cover  the  surface  of  wounds.  The 
foil  is  sterilized  by  dry  heat  and  placed  directly  on  the 
surface  of  the  wound  after  it  has  been  closed  by  sutures. 
It  is  claimed  that  the  foil  prevents  infection  of  the  wound 
from  the  exterior,  and  also  destroys  micro-organisms 
which  may  come  in  contact  with  it. 

Mackintosh. — This  consists  of  cotton-cloth,  with  a  thin 
layer  of  India-rubber  spread  on  one  side.  It  is  employed 
in  antiseptic  dressings  outside  of  the  gauze,  and  should 
be  applied  with  the  rubber  surface  toward  the  wound,  to 
prevent  the  entrance  of  air  and  to  allow  the  serum  from 
the  wound  to  permeate  the  gauze,  and  not  soak  directly 
through  the  dressings. 

The  mackintosh  cloth  is  not  at  the  present  time  as  much 
employed  as  formerly,  unless  the  method  of  moist  dressing 
is  adopted. 

Rubber-dam. — This  is  a  thin,  pure  rubber-tissue,  and 
as  it  has  no  cloth  surface,  like  mackintosh,  it  may  be 
cleansed  and  sterilized  with  greater  facility.  It  is  used  in 
the  method  of  moist  dressing  to  cover  the  gauze  dressings, 
and  is  attached  to  the  drainage-tube  in  abdominal  wounds 
to  shut  oif  the  opening  of  the  tube  from  the  abdominal 
wound.  Before  being  used,  it  should  be  washed  with  soap 
and  water,  rinsed,  and  then  placed  in  a  bichloride  or  car- 
bolic solution  for  a  time  sufficient  to  sterilize  it. 

Rubber-tissue. — This  consists  of  a  very  thin  sheet  of 
India-rubber  with  glazed  surfaces,  which  can  be  obtained 
from  the  rubber-manufacturers ;  it  is  employed  for  the 
same  purposes  as  the  mackintosh,  is  much  less  expensive, 
and,  as  previously  stated,  may  be  used  when  properly 
sterilized  instead  of  protective  for  covering  the  wound. 


MATERIALS   USED  IN  ASEPTIC  OPERATIONS.    145 

Gauze  Dressings. 

The  most  convenient  and  cheapest  material  for  wound 
dressing  is  a  material  known  to  the  trade  as  cheese-cloth 
or  tobacco-cloth,  and  for  surgical  use  should  contain  no 
sizing.  From  the  fact  that  it  has  a  very  open  mesh,  it 
absorbs  well  either  the  materials  with  which  it  is  pre- 
pared or  the  discharges  from  the  wound,  and  is  soft  and 
pliable,  so  that  it  is  a  comfortable  form  of  dressing  to  the 
patient. 

Gauze  containing  various  antiseptic  substances  was 
formerly  much  employed  in  surgical  dressings,  but  at  the 
present  time  it  has  been  largely  superseded  by  sterilized 
gauze. 

Bichloride  or  Corrosive  Sublimate  Gauze. — Bichlo- 
ride or  corrosive  sublimate  gauze  is  prepared  by  placing 
cheese-cloth  in  a  washing-kettle  and  covering  it  with 
water  to  which  is  added  two  pounds  of  washing-soda  or  a 
pint  of  lye;  the  latter  is  added  to  dissolve  any  oily  matter 
which  the  cheese-cloth  contains,  thus  making  it  more 
absorbent.  The  gauze  is  boiled  in  this  solution  for  an 
hour,  and  is  then  removed  and  washed  in  boiled  water 
and  passed  through  a  sterilized  clothes-wringer;  it  is  then 
immersed  in  a  1  :  1000  bichloride  solution  for  twenty-four 
hours  ;  the  excess  of  fluid  is  then  squeezed  out  of  it,  and 
it  may  be  packed  in  air-tight  jars  and  preserved  as  a 
moist  gauze,  or  may  be  dried  in  a  warm  oven  and  packed 
in  sterilized  jars  and  kept  as  a  dry  gauze.  Dry  bichloride 
gauze,  unless  freshly  prepared,  possesses  little  antiseptic 
properties. 

In  using  the  sublimate  gauze  on  delicate  skins  a  der- 
matitis sometimes  results,  which  is  known  as  mercurial 
eczema  ;  this  is  particularly  apt  to  occur  if  the  gauze  is 
moistened  or  covered  with  rubber-tissue  or  mackintosh. 
If  this  condition  develops,  the  parts  covered  by  the  gauze 
should  be  rubbed  over  with  boric  acid  ointment  or  vase- 
line before  it  is  reapplied,  or  a  sterilized  gauze  dressing 
should  be  substituted. 

Iodoform   Gauze. — This   may  be  prepared  by  soaking 

10 


146  MINOR  SURGERY. 

sterilized  gauze  in  a  mixture  containing  iodoform,  5  parts; 
glycerin,  20  parts ;  and  alcohol,  75  parts.  This  furnishes 
the  5  per  cent,  iodoform  gauze  ;  if  10  per  cent,  gauze  is 
desired,  the  quantity  of  iodoform  should  be  doubled. 
When  the  gauze  is  thoroughly  saturated,  it  should  be  of  a 
uniform  yellow  color.  It  should  then  be  thoroughly 
wrung;  out  with  sterilized  hands  to  remove  the  alcohol, 
and  packed  in  sterilized  jars  with  tight-fitting  covers. 

Iodoform  gauze  may  also  be  prepared  by  saturating 
sterilized  gauze  with  a  mixture  of  ether  and  iodoform, 
and  then  allowing  the  ether  to  evaporate,  the  iodoform 
being  distributed  evenly  through  the  gauze. 

Carbolized  Gauze. — In  preparing  carbolized  gauze, 
cheese-cloth  which  has  previously  been  boiled  and  dried 
is  soaked  for  a  few  hours  in  the  following  solution  :  resin, 
16  ounces  ;  alcohol,  5  pints  ;  castor  oil,  24  ounces  ;  carbolic 
acid,  12  ounces.  The  gauze  is  removed  from  this  solution 
and  passed  through  a  sterilized  clothes-wringer,  and  is 
then  cut  into  pieces  from  four  to  six  yards  in  length, 
which  are  folded  and  packed  in  air-tight  jars  for  use. 

Improvised  Aseptic  or  Antiseptic  Dressings. — 
Aseptic  dressings  in  cases  of  emergency  may  be  impro- 
vised, where  the  ordinary  gauze  dressings  cannot  be  ob- 
tained, by  tearing  muslin  or  mosquito-netting  into  pieces 
half  a  yard  square  and  placing  them  in  boiling  water  for 
a  few  minutes  ;  they  are  then  removed,  the  excess  of  moist- 
ure is  wrung  out,  and  they  are  applied  to  the  wound. 

If  it  is  desirable,  they  may  be  used  as  antiseptic  dress- 
ings by  soaking  them  for  a  few  minutes  in  a  1  :  1000  or 
1  :  2000  bichloride  solution,  or  in  a  5  per  cent,  carbolic 
solution.  This  dressing  will  keep  the  wound  aseptic  until 
a  more  elaborate  dressing  can  be  obtained. 

Sterilized  Bandages. — Sterilized  bandages  are  pre- 
pared by  tearing  or  cutting  gauze  into  strips  from  two  and 
a  half  to  three  inches  in  width,  and  forming  these  strips 
into  rollers,  which  are  sterilized  by  steam  or  dry  heat. 
They  should  be  used  soon  after  being  prepared,  or,  if  kept 
for  any  time,  should  be  resterilized  before  being  used. 

Bichloride    Cotton. — This    material    is    prepared    by 


MATERIALS    USED  IN  ASEPTIC  OPERATIONS.    147 

soaking  absorbent  cotton  in  a  1  :  1000  bichloride  solution 
for  twenty-four  hours,  and  allowing  it  to  dry,  or  it  may 
be  dried  in  a  hot  oven  ;  when  dry,  it  is  packed  in  jars  or 
in  air-tight  boxes.  Several  layers  of  bichloride  cotton 
are  usually  applied  over  the  gauze  dressing,  as  its  great 
absorbing  power  and  elasticity  make  it,  when  properly 
prepared,  a  most  valuable  dressing.  Borated,  carbolized, 
and  salicylated  cotton,  prepared  in  the  same  manner,  are 
also  frequently  employed  for  similar  purposes. 

Sterilized.  Cotton. — Sterilized  cotton  is  prepared  by 
placing  absorbent  cotton,  enclosed  in  perforated  metal 
cans,  in  a  steam  sterilizer  and  allowing  it  to  remain  for 
half  an  hour  under  ten  pounds  pressure.  It  is  used  for 
the  same  purposes  in  dressings  as  the  bichloride  cotton. 

Moist  Sterilized  Gauze  Dressings. — Moist  sterilized 
gauze  dressings  may  be  prepared  by  subjecting  gauze 
wThich  has  been  boiled  in  soda  solution  to  the  action  of 
boiling  water  or  of  steam  for  thirty  minutes.  Gauze  thus 
treated  should  be  used  as  soon  as  prepared. 

Sterilized  Gauze. — This  is  prepared  by  cutting  pieces 
of  gauze  the  desired  size,  wrapping  them  in  a  towel, 
and  placing  them  in  wire  baskets ;  or  the  gauze  may  be 
placed  in  cylindrical  tin  boxes,  3  inches  in  diameter 
and  8  inches  in  height,  with  perforated  metal  covers, 
covering  the  gauze  at  each  end  with  a  laver  of  cotton 
before  putting  on  the  covers.  The  gauze  is  next  placed 
in  a  steam  sterilizer  and  subjected  to  ten  pounds  pressure 
of  live  steam  for  half  an  hour.  The  steam  is  then  shut 
off  from  the  sterilizer  and  allowed  to  circulate  in  the 
jacket  of  the  apparatus  without  pressure  for  half  an  hour, 
to  dry  the  dressings.  If  the  gauze  has  been  sterilized  in 
metal  cases,  it  may  be  kept  for  some  time  and  still  remain 
sterile.     Cotton  may  be  sterilized  in  the  same  manner. 

Dry  Sterilized  Gauze  Dressings. — Dry  sterilized 
gauze  dressings  are  prepared  by  cutting  gauze  into  proper 
lengths  and  packing  it  loosely  in  wire  cages  or  perforated 
metal  cans,  which  are  next  placed  in  a  dry  sterilizing- 
oven  for  several  hours,  and  upon  removal  it  is  placed  in 
air-tight  jars   or  metal  boxes.     In   using  sterilized  gauze 


148 


MINOR  SURGERY. 


dressings,  it  is  safer  to  have  the  dressings  freshly  steril- 
ized immediately  before  each  operation.  A  convenient 
form  of  sterilizing-oven  is  shown  in  Fig.  122.  Towels 
and  operating-gowns  may  be  sterilized  in  the  same  oven. 

Fig.  122. 


Hot-air  sterilizer. 


Surgical  Operating-bag. — For  operations  in  private 
practice,  the  surgeon  will  find  it  convenient  to  have  a  bag 
or  kit  containing  gauze  dressings,  bichloride  pellets,  car- 
bolic acid,  alcohol,  turpentine,  ligatures,  sutures,  needles, 
syringes,  a  metal  tray  in  which  instruments  may  be  boiled, 
a  nest  of  small  agate-ware  basins,  sponges,  gauze  pads,  a 
sheet  of  rubber  cloth,  drainage-tubes,  and  operating- 
gown.  These  can  all  be  packed  in  a  comparatively  small 
space,  and  when  the  surgeon  is  called  upon  to  perform  any 
special  operation  at  short  notice  the  instruments  required 


ASEPSIS  IN  THE  TREATMENT  OF    WOUNDS.     149 

may  be  selected,  wrapped  in  a  Canton -flannel  scroll,  and 
placed  in  the  bag-.  Much  time  will  be  saved  by  having 
the  materials  required  in  operations  always  in  readiness. 


METHODS   AND   DRESSINGS   EMPLOYED    TO    SECURE 
ASEPSIS  IN  THE  TREATMENT  OF  WOUNDS. 

To  prevent  infection  of  wounds,  the  various  chemical 
sterilizers  and  dressings  are  employed  in  different  ways, 
and  the  principal  types  of  dressings  are  as  follows : 

Method  by  Simple  Drying. — This  method  is  employed 
in  small  and  not  very  deep  wounds.  The  edges  having 
been  brought  together  bv  sutures,  the  surface  of  the 
wound  is  dusted  with  powdered  iodoform,  the  serum  and 
blood  forming  with  this,  as  it  dries,  a  scab,  which  protects 
the  wound  from  infection  from  without;  repair  taking 
place  promptly  under  this  scab.  Treves  employs  this 
method  of  dressing  in  compound  fractures.  A  pledget 
of  gauze  saturated  with  iodoform-collodion  or  tr.  benzoin, 
oj ;  collodion,  ovij,  may  be  employed  instead  of  iodoform. 
Dry  sterilized  gauze  and  cotton  dressings  may  also  be 
employed  in  this  method  of  dressing. 

Method  by  Drying  and  Chemical  Sterilization. — 
The  object  of  this  method  of  dressing  is  to  provide  a 
means  of  sterilizing  the  blood  or  serum  which  escapes 
from  the  wound,  and  at  the  same  time  to  insure  the  ster- 
ilization of  the  air  coming  in  contact  with  the  discharges 
from  the  wound.  It  is  employed  in  large  or  deep  wounds, 
where  there  is  always  more  or  less  escape  of  blood  or 
serum,  and  is  accomplished  by  applying  a  number  of 
layers  of  sublimate  or  iodoform-gauze  and  sublimated 
cotton  over  the  wound.  Evaporation  not  being  interfered 
with,  the  whole  dressing  becomes  hardened,  and  the  wound 
is  surrounded  by  a  large  antiseptic  crust  made  up  of  the 
dressing  and  serum  or  blood. 

Moist  Dressings. — In  this  method  of  dressing,  the 
wound  is  covered  by  layers  of  moist  antiseptic  gauze, 
which  are  kept  moist  and  evaporation  prevented  by  apply- 


150  MINOR  SURGERY. 

ing  over  them  some  impervious  material,  such  as  mackin- 
tosh or  rubber-tissue. 

Modified  Moist  Dressing. — In  using  this  method,  the 
wound  itself  is  covered  by  a  piece  of  protective  or 
rubber-tissue  ;  over  this  is  placed  the  sublimated  or  iodo- 
form-gauze  dressing  and  some  layers  of  bichloride  cotton. 
In  this  way  the  wound  itself  is  kept  in  a  moist  condition 
favoring  particularly  the  organization  of  blood-clots ;  the 
external  dressings  become  dry  as  the  discharges  which 
have  escaped  into  them  evaporate,  forming  an  antiseptic 
crust  or  covering  over  the  wound. 

Preparation  for  Aseptic  Operation. 

Preparation  of  Room. — In  hospital  practice,  suitable 
operating-rooms  are  provided;  in  private  practice,  how- 
ever, the  surgeon  is  often  called  upon  to  select  a  room 
and  give  directions  as  to  its  preparation.  A  well-lighted 
room  should  always  be  selected,  and  all  unnecessary 
articles  of  furniture,  such  as  ornaments,  pictures,  and 
curtains,  should  be  removed.  The  carpet  should  be 
taken  up  and  the  floor  scrubbed.  A  few  small  tables 
and  a  large  wooden  table  should  be  placed  in  the  room, 
having  previously  been  dusted  and  wiped  off  with  a 
bichloride  solution.  All  preparations  should  be  made, 
if  possible,  upon  the  day  before  the  operation,  as  the  stir- 
ring up  of  dust  incidental  to  the  change  in  furniture  in 
cleaning  the  room  on  the  day  of  operation  immediately 
before  the  time  set,  is  more  dangerous  than  no  cleaning 
of  the  room  whatever,  since  the  principal  contamination 
of  the  wound  is  likely  to  come  from  germs  contained  in 
the  dust.  In  case  of  emergency,  the  floor  may  be  well 
moistened  by  sprinkling  with  water  to  lay  the  dust.  The 
preparation  of  the  room  is  not,  in  my  judgment,  a  matter 
that  affects  the  results  of  operations  as  much  as  does  the 
exercise  of  great  care  in  regard  to  aseptic  details  of  the 
operation  itself. 

Preparation  of  the  Patient. — The  skin  always  con- 
tains micro-organisms,    which    develop  upon    it  and  are 


STERILIZATION  OF  THE  FEET.  151 

constantly  being  deposited  upon  it  from  the  air.  Wei 
can  scarcely  hope  to  obtain  absolute  sterilization  of  the 
skin  under  these  circumstances,  but  by  careful  prepara- 
tion seek  to  obtain  that  relative  sterility  which  enables 
us  to  obtain  primary  union.  The  patient  should  be  given 
a  general  bath  the  night  before  the  operation,  and  the 
skin  surrounding  the  site  of  operation  should  be  thor- 
oughly scrubbed  with  a  brush  and  soap  and  water ;  or  a 
soap  poultice  may  be  applied  to  the  part  for  a  few  hours 
before  the  final  sterilization  with  alcohol  and  bichloride 
is  made.  In  scrubbing  the  skin  a  soft  brush  should  be 
used,  since  too  forcible  scrubbing  may  cause  irritation  or 
dermatitis.  After  this  scrubbing  has  been  continued  for 
a  few  minutes  the  skin  is  washed  with  alcohol  and  ether, 
then  douched  with  sterilized  water,  and  there  should  be 
applied  to  the  surface  a  folded  towel  or  gauze  dressing 
saturated  with  a  1  :  1000  bichloride  solution  ;  or  if  a  moist 
dressing  is  uncomfortable  to  the  patient,  a  few  layers  of 
sterilized  gauze  should  be  placed  over  the  surface  and  held 
in  place  by  a  bandage.  A  similar  washing  and  prepara- 
tion of  the  seat  of  operation  should  be  made  the  next 
morning,  a  few  hours  before  the  time  fixed  for  operation. 

The  skin  may  also  be  sterilized  by  formalin.  It  should 
first  be  scrubbed  thoroughly  with  soap  and  water,  and  then 
a  few  layers  of  gauze  saturated  with  a  1  per  cent,  solution 
of  formalin  should  be  laid  over  it  and  covered  by  an  im- 
permeable dressing.  This  solution  should  be  kept  in  con- 
tact with  the  skin  for  twenty-four  or  thirty-six  hours,  the 
compress  being  changed  every  twelve  hours. 

It  is  well  to  remember  that  regions  of  the  body  which 
contain  hair  and  numerous  sweat-glands,  such  as  the  axilla, 
navel,  scrotum,  groin,  and  the  creases  about  the  joints,  are 
those  in  which  micro-organisms  grow  with  the  greatest 
activity.  All  the  surrounding  hair  should  be  shaved  off ; 
and  if  the  operation  be  upon  the  skull,  it  is  well  to  shave 
the  scalp  completely. 

Sterilization  of  the  Feet. — There  is  usually  present 
upon  the  feet  a  large  amount  of  thickened  epidermis, 
which  renders  their  sterilization  difficult.     The  feet  should 


152  MINOR  SURGERY. 

be  washed  thoroughly  with  soap  and  water  and  scrubbed 
vigorously  with  a  brush ;  or  a  soap  poultice  should 
be  applied  to  the  whole  surface  of  the  feet  for  some  hours 
and  held  in  position  by  a  bandage.  A  moist  dressing 
favors  separation  of  the  superficial  layers  of  the  epi- 
dermis, and  after  it  has  been  worn  for  a  few  hours  it  is 
possible  to  remove  a  large  amount  of  the  latter  by  the  use 
of  the  brush.  After  having  been  washed  thoroughly  with 
a  1  :  1000  bichloride  solution  they  should  be  wrapped  in  a 
towel  or  a  feAV  layers  of  gauze  saturated  with  bichloride  of 
mercury  solution,  1  :  1000. 

Sterilization  of  the  Vagina. — The  vagina  and  external 
genitals  require  great  care  in  their  sterilization.  Accord- 
ing to  Schimmelbusch,  the  best  method  of  sterilizing  the 
vagina  is  to  dilate  it  fully  with  a  speculum,  and  to  scrub  it 
thoroughly  with  pads  of  gauze  saturated  with  green  soap 
and  water,  and  after  this  cleansing,  to  irrigate  it  with  a 
1  :  2000  bichloride  solution  or  a  1  per  cent,  solution  of 
kreolin. 

Sterilization  of  the  Bladder  and  Urethra. — It  is 
impossible  to  sterilize  completely  the  mucous  membrane 
of  the  bladder.  The  bladder  should  be  emptied  by  cath- 
eter and  filled  with  sterile  water  or  normal  salt  solution  ; 
this  procedure  should  be  repeated  several  times.  The  best 
means  we  have  at  our  disposal  at  the  present  time  of  steril- 
izing the  mucous  membrane  of  the  bladder  consists  in  irri- 
gating the  organ  frequently  with  a  10  grain  to  the  ounce 
solution  of  boric  acid  in  boiled  water.  In  operations  upon 
the  urethra  the  same  care  should  be  taken  to  render  the 
urethra  sterile  by  free  irrigation  with  normal  salt  solution 
or  boric  acid  solution. 

Sterilization  of  the  Stomach. — The  stomach  should 
be  sterilized  by  thorough  lavage  with  normal  salt  solution 
or  boric  acid  solution.  This  is  important,  not  only  in  op- 
erations upon  the  stomach  itself,  but  also  in  operations 
upon  the  pharynx,  to  diminish  the  risk  of  infection  by 
vomited  matter.  In  cases  of  intestinal  obstruction  with 
vomiting,  lavage  of  the  stomach  should  always  be  em- 
ployed before  operation. 


STERILIZATION  OF  THE  HANDS.  153 

Sterilization  of  the  Rectum. — When  an  operation  is 
to  be  performed  upon  the  anus  and  rectum,  the  patient 
should  be  given  a  purgative  and  an  enema  some  hours  be- 
fore the  operation,  to  remove  any  fecal  matter  which  may 
be  in  the  rectum.  The  region  of  the  anus  should  be  dis- 
infected with  soap  and  water  and  thoroughly  scrubbed,  and 
after  the  patient  lias  been  anaesthetized  the  sphincter  should 
be  well  stretched  and  the  rectum  irrigated  with  a  boric 
acid  solution.  A  tampon  of  sterilized  gauze,  with  a  string 
attached,  should  be  packed  into  the  rectum  above  the  seat 
of  operation,  to  prevent  the  wound  from  becoming  soiled 
with  feces  during  the  operation.  The  tampon  can  be  re- 
moved by  means  of  the  string  after  the  operation  has  been 
completed. 

Sterilization  of  the  Scalp. — Great  care  should  be  ob- 
served in  sterilizing  the  scalp  before  operations  on  the 
scalp  or  brain,  as  the  scalp  is  often  covered  by  dense 
masses  of  epidermis.  The  entire  scalp  should  be  shaved 
and  a  soap  poultice  applied  for  twelve  hours,  or  the  appli- 
cation of  sweet  oil  for  twenty-four  hours  before  the  use  of 
the  soap  poultice  may  be  of  use  in  softening  the  epidermis. 
It  should  be  rubbed  thoroughly  with  soap  and  water,  and 
finally  with  a  1  :1000  bichloride  solution. 

Sterilization  of  the  Mouth  and  Nasal  Cavities. — To 
render  the  mouth  as  far  as  possible  sterile,  the  teeth  should 
be  thoroughly  brushed  with  tooth-powder  and  the  cavity 
of  the  mouth  frequently  rinsed  with  a  solution  of  peroxide 
of  hydrogen,  1  part  to  6  parts  of  water,  or  with  a  satu- 
rated solution  of  boric  acid.  The  nasal  cavities  and  the 
post-nasal  region  should  be  sterilized  by  spraying  them 
with  the  same  solution. 

Sterilization  of  the  Hands. — The  difficulty  of  com- 
pletely sterilizing  the  hands  has  been  shown  by  bacterio- 
logical tests,  for  it  has  been  demonstrated  that  after  great 
care  in  the  process  complete  sterility  could  be  obtained 
only  in  about  95  per  cent,  of  the  tests.  The  hands 
of  the  surgeon,  unless  properly  sterilized,  may  be  the 
most  efficient  agents  in  producing  infection  of  the  wound; 
the  region  of  the  finger-nails  and  the  inter  digital  folds  are 


154  MINOR  SURGERY. 

locations  where  germs  are  particularly  abundant.  The 
hands  and  forearms  of  the  surgeon,  assistants,  and  nurses 
who  are  to  take  part  in  the  operation,  may  be  sterilized 
by  first  rubbing  them  with  spirit  of  turpentine,  and  then 
thoroughly  scrubbing  them  with  Castile  soap  and  water, 
using  a  nail-brush  freely.  Care  should  be  taken  that  the 
brush  is  sterilized.  This  scrubbing  should  be  employed 
for  several  minutes;  the  hands  are  then  rinsed  to  remove 
the  soap,  and  are  soaked  for  two  minutes  in  a  1  :  1000 
bichloride  of  mercury  solution.  If  turpentine  has  not  been 
employed  before  washing  with  the  soap,  strong  alcohol  or 
ether  should  be  rubbed  well  over  the  hands  before  they 
are  immersed  in  the  bichloride  solution.  When  the  hands 
have  been  sterilized  they  should  not  be  brought  in  contact 
with  anything  that  is  not  sterile. 

Permanganate  of  Potassium  and  Oxalic  Acid. — A  method 
of  sterilizing  the  hands  which  is  very  satisfactory  is  that 
employed  by  Kelly,  which  consists  in  washing  the  hands 
and  forearms  with  soap  for  ten  minutes,  and  then  soaking 
them  for  a  few  minutes  in  a  warm  saturated  solution  of 
permanganate  of  potassium,  which  stains  them  a  deep 
mahogany  color  ;  they  are  then  washed  in  a  warm  satu- 
rated solution  of  oxalic  acid  until  all  the  permanganate 
stain  is  removed,  and  should  next  be  washed  in  sterilized 
water  to  remove  the  oxalic  acid  which  may  adhere  to  the 
skin. 

Chloride  of  Lime  and  Carbonate  of  Sodium. — AVeir 
recommends  the  following  method  of  sterilizing  the 
hands.  After  washing  them  with  green  soap,  put  a  table- 
spoonful  of  commercial  chloride  of  lime  and  an  equal 
amount  of  carbonate  of  sodium  (washing-soda)  in  the 
hand,  with  enough  water  to  make  a  paste.  Rub  this  into 
a  thick  cream,  which  should  be  rubbed  into  the  hands 
until  the  grains  of  lime  disappear  and  the  skin  feels  cool. 
The  hands  are  then  rinsed  in  sterile  water.  This  method 
of  sterilization  of  the  hands  has,  in  my  experience,  been 
most  satisfactory. 

Sterilization  of  Instruments. — The  sterilization  of 
instruments  may  be  accompli  shed  by  dry  or  moist  heat; 


STERILIZATION  OF  CATHETERS.  155 

they  should  be  placed  in  a  hot-air  sterilizer  or  baked  for 
twenty  minutes  in  a  hot  oven.  Sterilization  of  instru- 
ments by  dry  heat  or  baking  is  not  often  employed,  as  it 
is  apt  to  spoil  the  temper  of  the  steel.  Instruments  may 
be  sterilized  by  the  method  suggested  by  Schimmelbusch, 
now  almost  universally  employed,  which  consists  in  boil- 
ing them  for  fifteen  minutes  in  water  to  which  a  table- 
spoonful  of  washing-soda  (carbonate  of  sodium)  has  been 
added  for  each  quart  of  water ;  this  prevents  the  rusting 
of  the  instruments,  and  also  makes  the  water  a  better  sol- 
vent for  any  fatty  matter  which  may  be  upon  the  instru- 
ments, thus  increasing  the  sterilizing  effect  of  the  heat. 
If  wooden-handled  instruments  are  used,  which  would 
be  injured  by  boiling,  they  should  first  be  thoroughly 
scrubbed  with  soap  and  water  and  a  brush,  and  after 
having  been  rinsed  in  sterilized  water  they  should  be  placed 
in  a  tray  and  covered  with  1  :  20  watery  solution  of  car- 
bolic acid,  and  allowed  to  remain  in  this  solution  for  at 
least  half  an  hour;  before  being  used  they  should  be 
transferred  to  a  bath  of  sterilized  water,  which  will  prevent 
the  benumbing  effect  of  the  carbolic  solution  upon  the 
surgeon's  hands. 

Instruments  may  also  be  sterilized  by  formalin  :  the 
latter  is  generated  by  heating  pastilles  of  paraform  with 
Sehering's  formalin  lamp.  The  instruments  are  placed 
in  racks  in  a  metal  ease,  and  by  burning  from  10  to  15 
grains  of  paraform  the  instruments  may  be  rendered 
sterile  in  fifteen  minutes. 

Instruments  which  fall  upon  the  floor  or  come  in  con- 
tact with  the  clothing  of  the  surgeon  or  of  the  patient 
during  the  operation,  should  again  be  sterilized  before 
being  brought  in  contact  with  the  wound. 

Sterilization  of  Catheters  and  Bougies.  —  These,  if 
made  of  metal  or  glass,  may  be  sterilized  by  boiling  for 
ten  minutes  in  a  1  per  cent,  solution  of  sodium  carbonate. 
If  constructed  of  rubber  or  gum,  prolonged  boiling 
destroys  them  ;  these  may,  however,  be  sterilized  by  first 
washing  them  with  soap  and  water  and  then  placing  them 
for  fifteen  minutes  in  a  1  per  cent,  solution  of  sodium 


156  MINOR  SURGERY. 

carbonate,  heated  nearly  to  the  boiling-point ;  they  are 
next  placed  in  a  1  :  1000  bichloride  solution  until  required. 
They  should,  on  being  removed  from  this  solution  for  use, 
be  soaked  thoroughly  in  hot  sterile  water  to  remove  all 
the  bichloride  solution.  Rubber  catheters  may  also  be 
sterilized  by  soaking  them  for  an  hour  in  a  2  per  cent, 
solution  of  formalin,  or  by  placing  them  in  an  air-tight 
metallic  case  or  glass  jar  containing  pastilles  or  paraform. 
They  can  be  kept  indefinitely  in  such  a  receptacle,  and 
when  removed  for  use  should  be  washed  in  sterilized 
water.  For  lubricating  catheters  and  bougies,  oily  mate- 
rials should  be  avoided,  and  sterilized  glycerin  or  lubri- 
chondrin,  both  of  which  are  soluble  in  water,  should  be 
employed. 

Rubber  Gloves. — These  gloves  are  now  extensively 
employed  in  operative  work,  and  the  results  following 
their  use  have  been  most  satisfactory.  They  are  made  of 
very  thin  rubber,  so  that  there  is  little  interference  with 
tactile  sensation,  and  from  their  elasticity  they  tit  the 
hands  accurately.  They  can  be  rendered  absolutely  ster- 
ile, and  as  they  are  impervious  to  moisture  there  is  no 
risk  of  wound  infection  if  the  hand  is  not  completely 
sterilized  unless  the  gloves  have  been  torn  or  punctured. 
They  may  be  sterilized  by  first  washing  them  with  soap 
and  water,  and  then  immersing  them  for  twenty-four  hours 
in  a  1  :1000  bichloride  solution.  The  better  method  of 
sterilization,  however,  consists  in  wrapping  them  in  a 
towel  and  boiling  them  for  ten  minutes  in  a  1  per  cent, 
solution  of  carbonate  of  sodium.  They  are  usually 
applied  by  filling  them  with  sterilized  water  or  salt  solu- 
tion, and  then  introducing  the  hand ;  some  operators 
prefer  to  apply  them  dry  to  the  hand,  using  a  dry  sterilized 
powder,  such  as  starch  or  soapstone.  If  properly  cared 
for,  a  pair  of  gloves  will  withstand  a  number  of  steriliza- 
tions. A  freshly  sterilized  pair  of  gloves  should  be  used 
for  each  operation. 

Cotton  or  silk  gloves,  which  have  been  sterilized  by 
boiling  or  by  dry  heat,  have  been  recommended  by 
Mikulicz  and  other  surgeons,  to  be  worn  during  opera- 


DETAILS  OF  AN  ASEPTIC  OPERATION.  157 

tions.     Experiments,  however,  have  shown  that  cotton  or 
silk  gloves  are  not  as  safe  as  those  made  of  rubber. 
Clothing  of  Surgeon  and  Assistants. — The  surgeon 

and  his  assistants  should  wear  sterilized  linen  or  muslin 
suits,  or  be  provided  with  gowns  with  sleeves  reaching  to 
the  elbows,  for  the  protection  both  of  the  patient  and  of 
their  clothing.  The  operating-gown  should  be  made  of 
muslin  or  linen,  which  can  easily  be  sterilized  by  boiling 
or  heat ;  a  variety  of  linen  known  as  butchers'  linen  is  very 
serviceable  for  this  purpose.  As  a  matter  of  additional 
precaution,  many  surgeons  and  their  assistants  wear  dur- 
ing the  operation  closely  fitting  skull-caps  of  linen,  and 
wear  over  the  nose  and  mouth  a  pad  composed  of  a  num- 
ber of  layers  of  sterilized  gauze,  to  prevent  infection  of  the 
wound  by  the  expired  air.  The  surgeon  and  assistants 
will  often  find  it  convenient  to  wear  under  their  linen 
gowns  India-rubber  aprons,  to  prevent  soiling  of  the 
clothing  bv  blood  or  solutions.  The  nurses  should  wear 
sterilized  linen  or  muslin  operating-gowns  and  dresses  of 
washable  goods.  An  operating -apron  may  be  improvised 
from  a  clean  sheet  folded  so  as  to  be  one  and  a  half  yards 
in  width  and  from  five  to  six  feet  in  length,  by  turning  in 
about  ten  inches  of  one  end  of  the  sheet  over  the  upper 
part  of  the  chest  and  placing  a  strip  of  bandage  in  this 
fold,  which  should  be  secured  around  the  neck,  and  tying 
a  second  strip  of  bandage  over  the  sheet  at  the  waist. 

Details  of  an  Aseptic  Operation. — The  patient  being 
prepared  for  operation  as  described,  and  having  been 
anaesthetized,  is  placed  upon  the  operating-table,  the  sur- 
geon, assistants,  and  nurses  also  being  prepared  for  the  opera- 
tion as  previously  described.  If  the  operation  be  one  upon 
the  face,  neck,  or  chest,  it  is  well,  before  the  dressings 
covering  the  seat  of  operation  are  removed,  to  cover  the 
patient's  hair  with  a  towel  or  handkerchief-bandage  made 
of  several  layers  of  sterilized  or  bichloride  gauze.  The 
portions  of  the  patient's  body  which  it  is  not  necessary  to 
expose  in  the  operation  should  be  covered  with  a  woollen 
blanket,  and  this  covered  with  a  sterilized  sheet.  Some 
surgeons  prefer  to  have  the  patient  wear  a  sterilized  gown, 


158  MINOR  SURGERY. 

which  is  ripped  or  cut  to  expose  the  part  to  be  operated 
upon.  The  region  of  the  wound  and  the  operating-table 
are  next  protected  with  sterilized  towels  or  cloths.  The 
surgeon  having  assigned  the  assistants  and  nurses  their 
duties,  the  dressing  is  removed  from  the  part  to  be  oper- 
ated upon,  and  the  operation  is  begun.  Hemorrhage  is 
controlled  by  the  use  of  haemostatic  forceps,  and  steril- 
ized gauze  pledgets  are  employed  to  keep  the  wound 
free  from  blood.  When  the  operation  is  completed,  the 
vessels  are  ligated,  the  haemostatic  forceps  are  removed, 
and  the  wound  is  dried  with  gauze  pledgets.  If,  for 
any  reason,  the  surgeon  deems  it  advisable  to  irrigate 
the  wound,  it  may  be  done  with  hot  sterilized  water  or 
with  sterilized  salt  solution.  If  the  surgeon  decides  that 
drainage  is  not  necessary,  the  deeper  parts  of  the  wound 
may  then  be  brought  together  with  buried  sutures  of 
catgut  or  silk,  and  the  edges  of  the  superficial  wound  next 
approximated  by  sutures  of  catgut,  silk,  or  silkworm-gut. 
If  the  surgeon  decides  to  use  drainage,  before  closing  the 
wround  a  few  strands  of  catgut,  a  strip  of  sterilized  gauze, 
a  tent  of  rubber-tissue,  or  a  rubber  or  glass  drainage-tube 
is  introduced  into  the  deepest  portion  of  the  wound  and 
brought  out  at  its  most  dependent  part.  The  wound  is 
then  dressed  with  a  number  of  loose  masses  of  sterilized 
gauze  placed  so  as  to  cover  the  wound  and  extend  beyond 
it  in  all  directions,  and  these  are  covered  by  a  number  of 
layers  of  sterilized  gauze,  and  the  dressings  are  held  in 
place  by  a  gauze  bandage.  The  bandage  should  be  applied 
so  as  to  cover  the  cotton  at  the  edges  of  the  dressing,  and 
thus  make  the  occlusion  of  air  from  the  wound  as  complete 
as  possible.  Over  the  gauze  dressing  are  placed  a  few 
layers  of  sterilized  cotton,  extending  on  all  sides  well  beyond 
the  gauze,  and  the  dressings  are  held  in  place  by  a  steril- 
ized gauze  bandage.  The  dressings  should  be  voluminous ; 
it  is  always  a  mistake  to  apply  scanty  dressings.  In 
redressing  the  wound  the  same  care  should  be  exercised 
as  regards  asepsis  as  was  observed  at  the  primary 
dressing. 
Details  of  an  Antiseptic  Operation. — The  region  of 


DETAILS   OF  AN  ANTISEPTIC  OPERATION. 


L59 


the  wound  being  previously  sterilized  and  the  patient 
being  anaesthetized  and  placed  upon  the  table,  the  cloth- 
ing i.s  so  arranged  as  to  expose  freely  the  part  t<>  be  oper- 
ated upon  ;  the  clothing  or  the  skin  surrounding  this  region 
is  next  covered  with  towels  wet  with  a  1  :  1000  bichloride 
solution.  If  any  considerable  surface  of  the  patient's  body 
is  covered  by  these  towels,  to  avoid  chilling  the  surface  and 
adding  to  the  shock  which  naturally  follows  the  operation, 
they  should  be  wrung  out  in  a  hot  bichloride  solution,  and 

Fig.  123. 


Irrigating  apparatus.     (Esmarch.) 

should  be  replaced  as  they  become  cold  by  hot  towels  pre- 
pared in  the  same  manner.  The  patient  being  ready  for 
operation,  the  surgeon  should  assign  the  assistants  and 
nurses  their  duties,  and  having  previously  sterilized  his 
hands  and  forearms,  and  again  immersed  them  in  the  bi- 
chloride solution,  the  operation  is  begun. 

During  the  operation  the  wound  is  irrigated  frequently 
with  a  1  :  2000  to  1  :  4000  bichloride  solution,  which  may 
be  applied  to  the  wound  by  means  of  a  syringe  or  irrigat- 
ing apparatus  (Fig.  123),  and  the  hands  of  the  surgeon 
and  assistants  should  also  be  washed  in  this  solution  at 


160  MINOR  SURGERY. 

not  too  long  intervals.  In  prolonged  operations,  or  in 
those  in  which  a  large  wound  is  made,  it  is  especially 
important  that  the  irrigating  solutions  should  be  used  as 
warm  as  can  comfortably  be  borne  by  the  hands  of  the 
surgeon  ;  warm  solutions,  it  has  been  shown  by  recent 
investigations,  possess  a  greater  germicidal  power  than 
those  of  the  same  strength  when  used  cold,  and  they  also 
possess  the  advantage  of  preventing  chilling  of  the  patient, 
and  thus  diminish  the  shock  of  the  operation. 

Hemorrhage  during  the  operation  is  controlled  by  the 
use  of  haemostatic  forceps,  which  are  applied  to  the  bleed- 
ing vessels,  or  the  vessels  may  be  ligatured  as  they  are 
divided.  After  the  operation  has  been  completed,  and  all 
hemorrhage  has  been  controlled,  the  wound  is  thoroughly 
irrigated  with  a  1  :  4000  to  1  :  2000  bichloride  solution. 

The  next  step  is  to  provide  for  drainage ;  this  may  be 
disregarded  in  small,  superficial  wounds,  but  in  a  wound 
of  considerable  size  or  depth  it  is  safer  to  provide  free 
drainage.  This  is  accomplished  by  the  use  of  perforated 
rubber  drainage-tubes,  or  a  number  of  strands  of  catgut, 
or  strips  of  iodoform  or  bichloride  gauze. 

The  rubber  tube  may  be  laid  in  the  wound,  the  ends 
being  allowed  to  extend  from  the  extremities  of  the  wound, 
or  it  may  be  so  introduced  that  one  end  of  the  tube  rests 
in  the  deepest  part  of  the  wound  and  the  other  extremity 
is  brought  out  of  the  wound  at  its  most  dependent  portion  ; 
in  large  or  irregularly  shaped  wounds  a  number  of  tubes 
may  be  required  to  secure  free  drainage.  The  ends  of  the 
drainage-tubes  are  transfixed  with  safety-pins  which  have 
been  sterilized,  and  should  next  be  cut  off  close  to  the  pins 
so  as  to  be  as  nearly  as  possible  flush  with  the  skin.^ 

The  wound  being  closed  by  sutures,  a  final  irrigation  of 
its  deepest  parts  should  be  made,  by  injecting  a  stream  of 
bichloride  solution,  1  :  4000  to  1  :  2*000,  into  the  end  of  the 
drainage-tube.  The  external  surface  of  the  wound,  and 
the  skin  for  some  distance  surrounding  it,  should  next  be 
washed  with  a  1  :  4000  to  1  :  2000  bichloride  solution, 
and  a  piece  of  protective,  a  little  longer  and  wider  than 
the  wound,  is  dipped  in  a  bichloride  or  carbolic  solution 


MOIST  METHOD    OF   DBESSING.  161 

and  placed  over  it.  The  use  of  protective  over  the 
wound  is  important  only  if  it  is  desired  to  keep  the 
wound  moist,  in  order  to  obtain  organization  of  the  blood- 
clot,  otherwise  it  need  not  be  employed.  Over  this  is 
laid  the  deep  dressing,  which  consists  of  a  pad  of  bichlo- 
ride gauze  from  eight  to  sixteen  layers  in  thickness,  and 
large  enough  to  overlap  the  wound  two  or  three  inches 
in  all  directions.  This  should  be  dipped  in  a  1  :  4000  to 
1  :  2000  bichloride  solution,  and  wrung  out  as  dry  a.-  pos- 
sible before  being  applied.  The  superficial  gauze-dressing 
is  next  applied,  and  consists  of  sixteen  layers  of  gauze, 
which  should  be  large  enough  to  extend  from  three  to  six 
inches  beyond  the  wound  in  all  directions;  this  gauze  is 
applied  dry.  Over  the  superficial  gauze-dressing  there  is 
next  applied  a  number  of  layers  of  bichloride  cotton, 
so  arranged  as  to  extend  a  little  beyond  the  margin  of 
the  superficial  gauze-dressing.  These  dressings  are  next 
secured  in  position  by  the  application  of  a  gauze-bandage, 
which  is  prevented  from  slipping  by  the  introduction  of  a 
few  safety-pins.  Iodoform,  carbolized.  or  any  other  variety 
of  medicated  gauze,  may  be  used  in  place  of  the  bichloride 
gauze. 

In  this  method  of  dressing,  no  mackintosh  or  rubber- 
tissue  is  employed  outside  of  the  superficial  gauze-dress- 
ing ;  the  discharges  of  the  wound  are  disseminated  through 
the  dressing  and  become  dry  by  evaporation,  and  the 
dressing  forms  an  antiseptic  scab  which  covers  and  sur- 
rounds the  wound. 

Moist  Method  of  Dressing. — If,  for  any  reason,  it  is 
desired  to  adopt  the  moist  method  of  dressing,  a  piece  of 
mackintosh  or  rubber-tissue  larger  than  the  superficial 
gauze-dressing  is  placed  over  it,  and  over  this  are  placed 
a  few  layers  of  bichloride  cotton,  care  being  taken  to  see 
that  the  layers  of  cotton  overlap  the  mackintosh  or  rubber- 
tissue  by  a  few  inches;  the  application  of  an  antiseptic 
gauze-bandage  then  completes  the  dressing.  On  removal 
of  this  dressing  the  gauze  will  generally  be  found  to  be 
soaked  with  the  discharges  from  the  wound,  and  in  a 
moist  condition.  The  disadvantage  of  this  variety  of 
li 


162  MINOR  SURGERY. 

dressing  is  that  there  is  apt  to  be  more  irritation  of  the 
skin  set  up  by  the  bichloride  gauze  when  kept  moist  than 
when  applied  in  the  manner  of  a  dry  dressing. 

Redressings  of  the  Wound. — The  redressing  of  a 
wound  which  remains  aseptic  need  not  be  made  for  some 
days ;  if  the  temperature  remains  normal  or  a  little  above 
this  point,  and  the  patient  exhibits  no  unfavorable  con- 
stitutional symptoms,  and  the  dressing  is  comfortable  to 
the  patient,  it  need  not  be  disturbed  for  a  week  or  ten 
days ;  at  the  expiration  of  this  time  it  is  well  to  examine 
the  wound  and  to  remove  the  drainage-tube  if  drainage 
has  been  used,  and  to  remove  a  portion  or  all  of  the 
sutures  if  the  superficial  parts  of  the  wound  are  firmly 
healed 

In  redressing  a  wound  in  which  the  antiseptic  method 
was  employed,  at  the  end  of  a  week  or  ten  days,  to  pre- 
vent any  possible  infection,  as  much  care  should  be 
exercised  as  in  the  original  dressing  of  the  wound.  The 
patient's  clothes  should  be  removed  so  as  freely  to  expose 
the  dressing,  and  a  rubber  cloth  should  be  placed  under 
the  patient  so  as  to  protect  the  bed,  and  the  clothing  and 
skin  in  the  region  of  the  wound  should  be  protected  by 
towels  wrung  out  in  a  1  :  1000  bichloride  solution.  The 
surgeon  should  wash  his  hands  and  immerse  them  in  a 
1  :  1000  bichloride  solution  before  removing  the  dressings. 
The  bandage  retaining  the  dressing  should  be  divided  with 
bandage-scissors  and  the  gauze  removed  layer  by  layer, 
and  when  the  deep  dressing  is  removed  care  should  be 
taken  that  the  drainage-tubes  are  not  pulled  upon  if  they 
are  adherent  to  the  dressing ;  the  protective  should  next 
be  removed  and  the  surface  of  the  wound  irrigated  with  a 
1 :2000  bichloride  solution.  If  the  wound  is  found  aseptic, 
the  drainage-tube  may  be  removed,  and  the  superficial 
wound  be  irrigated  with  bichloride  solution.  If  the  wound 
is  healed,  the  sutures  maybe  removed  at  this  dressing;  but 
if  the  wound  has  been  an  extensive  or  deep  one,  it  may  be 
well  to  remove  only  a  portion  of  the  sutures ;  if  catgut 
sutures  have  been  employed,  they  need  not  be  removed. 
The  surface  of  the  wound  is  next  irrigated  with  a  1  ;  2000 


REDRESSING   OF   WOUNDS.  163 

bichloride  solution,  and  deep  and  superficial  gauze-dress- 
ings are  applied  as  previously  described,  and  covered 
with  layers  of  bichloride  cotton,  and  the  whole  dressing 
is  secured  by  the  application  of  an  antiseptic  bandage. 
If  the  wound  remains  aseptic,  the  dressings  need  not  be 
changed  for  a  week  or  ten  days,  and  at  this  time  the 
wound  will  usually  be  found  healed,  so  that  further  dress- 
ings are  not  required. 

In  the  redressing  of  a  wound  in  which  the  aseptic  method 
was  employed,  the  use  of  germicidal  solutions  is  omitted, 
and  the  wound  is  redressed  with  sterilized  gauze  and  cotton. 
If,  however,  the  wound  is  not  running  the  typical  course 
of  an  aseptic  wound,  constitutional  symptoms  will  be  de- 
veloped, as  evidenced  by  a  rise  in  the  temperature  and  pulse- 
rate  and  other  constitutional  disturbances.  In  this  event 
the  wound  should  be  redressed  as  soon  as  possible,  and  if 
the  cause  of  the  disturbance  can  be  found,  it  should  be 
removed  ;  for  instance,  hemorrhage  may  have  taken  place 
into  the  wound,  and  the  blood  not  being  able  to  escape 
through  the  drainage-tubes  may  have  caused  so  much  dis- 
tention of  the  wound  that  the  vitality  of  the  skin  cover- 
ing the  wound  is  threatened,  or  the  sutures  may  be  found 
to  be  causing  irritation,  or  suppuration  may  be  present. 

If,  on  exposure  of  the  wound,  it  is  found  that  it  is  dis- 
tended with  blood-clots,  and  that  blood  is  escaping  from 
the  wound,  the  sutures  should  be  removed,  the  clots 
turned  out,  and  the  bleeding  vessel  or  vessels  sought  for 
and  ligatured,  and  the  wound,  after  a  thorough  irrigation 
with  1  :  4000  to  1  :  2000  bichloride  solution,  should  be 
drained  and  closed  with  sutures,  and  dressed  as  previously 
described. 

If,  however,  on  exposure  of  the  site  of  the  operation, 
and  upon  the  removal  of  a  portion  or  all  of  the  sutures, 
the  wound  is  found  distended  with  a  blood-clot,  and  no 
evidence  of  hemorrhage  at  the  time  exists,  or  of  suppura- 
tion in  the  wound,  the  clot  may  be  allowed  to  remain  in 
place,  and  the  wound  should  be  redressed  as  in  the  original 
dressing,  trusting  to  the  organization  of  the  blood-clot  if 
it  has  remained  aseptic.     If  the  patient's  condition  im- 


164  MINOR  SURGERY. 

proves  after  the  dressing,  and  the  temperature  and  pulse- 
rate  become  normal,  it  is  an  indication  that  the  wound  is 
still  aseptic,  and  it  need  not  be  redressed  for  some  days. 

If,  on  the  other  hand,  examination  of  the  wound  shows 
that  the  drainage  is  insufficient,  or  that  the  drainage- 
tubes  are  occluded  by  blood-clots,  these  should  be  removed 
by  washing  out  the  tubes  with  a  1  :  4000  to  1  :  2000  bi- 
chloride solution  by  means  of  a  syringe,  and  introducing 
additional  drainage-tubes,  if  it  is  deemed  necessary ;  the 
wound  should  then  be  redressed. 

When  it  is  found  on  examination  of  the  wound  that 
suppuration  is  present,  it  should  thoroughly  be  irrigated 
through  the  drainage-tubes  with  a  1  :  2000  bichloride 
solution,  and  after  thorough  irrigation  it  should  be 
redressed,  and,  if  the  constitutional  symptoms  improve,  it 
may  be  assumed  that  the  wound  has  been  rendered  aseptic. 

Aseptic  or  Antiseptic  Treatment  of  Infected 
Wounds. — It  often  happens  that  the  surgeon  is  called 
upon  to  treat  a  wound  which  is  septic  Avhen  it  comes 
under  his  care,  as  evidenced  by  the  inflamed  state  of  the 
wound,  inflammation  of  the  lymphatic  vessels  and  skin, 
foul  discharges  and  sloughing  of  the  tissues,  and  the 
coexistent  constitutional  symptoms  of  sepsis.  In  such  a 
case  it  would  at  first  sight  appear  that  the  surgeon  or  his 
assistants  could  not  introduce  any  material  of  infection 
worse  than  that  which  already  existed  in  the  wound,  but 
he  should  bear  in  mind  the  fact  that  it  is  possible  to  intro- 
duce a  new  form  of  infection  in  addition  to  that  already 
existing.  With  this  possibility  in  view,  he  should  observe 
the  same  precautions  as  regards  the  sterilization  of  his 
hands,  the  region  of  the  wound,  the  instruments,  and 
dressings,  as  he  would  employ  in  treating  a  perfectly  fresh 
wound. 

Recent  investigations,  however,  have  shown  that  the 
germs  in  abscesses  are  to  a  great  extent  dead,  and  that 
the  pus-formation  is  largely  due  to  the  irritation  caused 
by  their  products.  In  view  of  these  facts,  it  would  seem 
that  the  most  important  part  of  the  treatment  of  infected 
wounds  is  thorough  drainage.     It  is  a  question  whether 


TREATMENT  OE  INFECTED    WOUNDS.  165 

the  micro-organisms  in  the  walls  of  infected  cavities  or 
sinuses  can  be  destroyed  by  antiseptic  irrigation.  Some 
surgeons  recommend  active  treatment,  both  mechanically 
and  by  the  use  of  germicidal  solutions,  while  others  are 
satisfied  simply  to  secure  free  drainage ;  and  if  irrigation 
is  necessary,  they  do  not  employ  strong  germicidal  fluids 
but  use  simply  sterilized  water  or  sterilized  salt  solution. 
I  prefer  to  employ  the  antiseptic  method  in  dealing  with 
infected  wounds,  and  can  recommend  the  following  plan. 
The  skin  surrounding  the  wound  for  some  distance  should 
be  wiped  over  with  spirit  of  turpentine  and  carefully 
scrubbed  with  soap  and  water,  and  should  next  be  washed 
with  a  1  :  1000  bichloride  solution  ;  the  wound  itself 
should  next  be  washed  with  peroxide  of  hydrogen  and  a 
1  :  1000  bichloride  solution.  With  forceps  and  curette, 
any  dirt  or  sloughing  tissue  should  be  removed  ;  then  the 
wound  again  washed  with  peroxide  of  hydrogen  and 
douched  with  a  1  :  2000  bichloride  solution.  The  wound 
should  then  be  dried  with  gauze  pledgets  and  dusted  with 
iodoform,  and  loosely  packed  with  strips  of  iodoform 
gauze.  If  from  the  appearance  of  the  tissues  the  surgeon 
has  reason  to  think  that  the  infection  has  passed  beyond 
the  reach  of  the  curette  or  scissors,  he  may  swab  over  the 
surface  of  the  wound  with  a  solution  of  chloride  of 
zinc,  30  grains  to  the  ounce  of  water.  Pure  carbolic  acid 
may  be  used,  and  is  recommended  by  some  surgeons,  for 
the  same  purpose  as  chloride  of  zinc,  but  the  toxic  action 
of  carbolic  acid  causes  its  employment  to  be  attended  with 
some  danger.  Toxic  effects  and  too  extensive  cauteriza- 
tion may  be  prevented  by  washing  the  part  with  abso- 
lute alcohol.  Free  drainage  being  secured  by  the  intro- 
duction of  a  few  strips  of  iodoform  gauze,  the  wound  is 
dressed  with  a  voluminous  dressing  of  bichloride  gauze 
and  bichloride  cotton.  No  attempt,  as  a  rule,  should  be 
made  to  bring  together  the  edges  of  such  a  wound  by  the 
introduction  of  sutures.  In  the  dressing  of  infected 
wounds,  when  the  discharges  are  ropy  or  viscid  they  are 
not  well  absorbed  by  dry  dressings,  and  in  this  class  of 
wounds   it  is,   therefore.,   often   of   advantage   to    employ 


166  MINOR  SURGERY. 

moist  antiseptic  dressings.  By  this  method  of  treatment 
it  is  often  possible  to  convert  a  septic  wound  into  an 
aseptic  one,  and  have  rapid  improvement  follow  both  in 
the  local  condition  of  the  wound  and  in  the  constitutional 
condition  of  the  patient. 


MATERIALS  USED  IN  SURGICAL  DRESSINGS. 

Lint. — This  material  is  employed  in  surgical  dressings, 
and  is  of  two  varieties  :  the  domestic  lint,  which  consists 
of  pieces  of  old  linen  or  muslin  which  have  been  thor- 
oughly washed  or  boiled  and  then  dried,  or  the  surgical 
lint,  which  resembles  Canton  flannel  in  appearance ;  the 
latter  is  the  best  material,  as  it  has  a  greater  absorbing 
capacity. 

Lint  is  used  as  a  material  on  which  unctuous  prepara- 
tions are  spread  in  the  dressing  of  wounds,  and  is  em- 
ployed also  as  a  material  for  saturating  with  the  various 
solutions  which  are  used  in  wet  dressings,  such  as  lead- 
water  and  laudanum ;  the  lint,  after  being  saturated  with 
the  solution,  is  covered  with  rubber-tissue  or  oiled  silk 
when  applied,  to  prevent  too  rapid  evaporation  of  the 
solution.  It  is  also  one  of  the  best  materials  from  which 
to  construct  the  compresses  employed  in  the  treatment  of 
fractures. 

Paper-lint. — This  is  made  from  old  rags  or  wood-pulp, 
has  great  absorbing  power  for  fluids,  and  may  be  used  as 
a  substitute  for  surgical  lint  in  the  application  of  wet 
dressings  to  surfaces  when  the  skin  is  unbroken. 

Oakum. — This  material,  made  from  old  tarred  rope, 
was  formerly  much  employed  in  the  dressing  of  wounds, 
before  the  introduction  of  the  antiseptic  method  of 
wound  treatment.  From  its  elasticity  it  is  found  to  be 
an  excellent  material  for  padding  splints  or  other  surgical 
appliances.  It  is  employed  also  in  the  form  of  pads  to 
place  under  patients  to  relieve  portions  of  the  body  from 
pressure,  or  to  absorb  discharges  which  soak  through  the 
dressings.     A  mass  of  oakum  which  has  been  well  teased 


ABSORB  EST  COTTON.  167 

out  and  wrapped  in  a  towel  forms  an  excellent  pillow  on 
which  to  support  a  stump. 

Cotton. — Cotton  is  now  employed  in  surgical  dressings 
principally  as  a  material  to  pad  splints  or  to  relieve 
salient  parts  of  the  skeleton  from  pressure  in  the  applica- 
tion of  splints  or  bandages ;  for  instance,  in  the  applica- 
tion of  the  plaster-of- Paris  bandage,  the  bony  prominences 
are  generally  covered  with  small  masses  of  cotton.  It  pos- 
sesses but  little  absorbent  power  unless  used  in  the  form 
of  absorbent  cotton,  and  is  not  much  employed  in  surgical 
dressings  except  for  the  purposes  mentioned  above. 

Absorbent  Cotton. — This  material  is  prepared  from 
ordinary  cotton,  which  is  boiled  with  a  strong  alkali  to 
remove  the  oily  matter  which  it  contains.  When  so  pre- 
pared, it  absorbs  liquids  freely,  and  by  reason  of  its  great 
absorbing  capacity  it  is  employed  largely  in  surgical  dress- 
ings. A  small  mass  of  sterilized  absorbent  cotton  wrapped 
upon  the  end  of  a  probe  is  now  generally  employed  to 
make  applications  to  wounds,  and  has  taken  the  place  of 
the  sponge  or  brush  which  formerly  was  employed  for  this 
purpose.  On  account  of  its  cheapness,  after  one  applica- 
tion it  can  be  thrown  away  and  a  new  piece  used,  and  thus 
the  danger  of  carrying  infection  from  one  wound  to  an- 
other by  the  applicator  is  abolished.  It  is  largely  em- 
ployed in  gynecological  practice  for  making  applications 
to  the  female  genital  organs. 

Wood-wool.  — Wood-wool  made  from  wood-pulp,  such 
as  is  employed  in  the  manufacture  of  paper,  is  also  fur- 
nished in  the  shape  of  lint,  sponges,  and  pads,  and  may 
be  used  for  the  same  purposes  as  the  ordinary  surgical 
lint. 

Oiled  Silk  or  Muslin. — These  materials  are  employed 
as  an  external  covering  for  moist  dressings  to  prevent 
rapid  evaporation  from  the  dressings ;  they  form  excellent 
materials  for  this  purpose,  but  as  they  are  quite  expensive 
their  use  is  limited. 

Waxed  or  Paraffin-paper. — This  dressing  is  prepared 
by  passing  sheets  of  tissue-paper  through  melted  wax  or 
paraffin,  and  then  allowing  them  to  dry.    Paper  thus  treated 


168  MINOR  SURGERY. 

forms  an  excellent  and  cheap  substitute  for  oiled  silk  or 
muslin,  and  may  be  employed  for  the  same  purpose  for 
which  the  latter  materials  are  used. 

Rubber-tissue. — This  material,  which  is  prepared  by 
rubber  manufacturers,  consists  of  rubber  run  out  into  very 
thin  sheets.  It  has  a  glazed  surface,  is  very  pliable,  and 
at  the  same  time  strong,  forming,  therefore,  a  cheap  and 
satisfactory  substitute  for  oiled  silk,  and  is  employed  for 
the  same  purposes. 

Parchment-paper. — This  paper  is  prepared  so  as  to 
render  it  water-proof;  it  is  employed  in  surgical  dressings 
for  the  same  purposes  as  oiled  silk  and  rubber-tissue. 

Compresses. — Compresses  are  prepared  by  folding  pieces 
of  lint,  muslin,  linen,  or  gauze  upon  themselves,  so  as  to 
form  firm  masses  of  variable  size ;  oakum  or  cotton  may 
also  be  used  to  form  compresses.  Compresses  are  em- 
ployed to  make  pressure  over  localized  portions  of  the 
body,  as  in  the  treatment  of  fractures,  or  to  make  press- 
ure upon  vessels  for  the  control  of  hemorrhage. 

Tampon. — A  tampon  is  -a  form  of  compress  which  is 
employed  in  cavities  to  make  pressure,  to  control  hemor- 
rhage, or  to  apply  various  solutions  or  powders  to  the 
surface  of  the  cavity.  Tampons  used  to  control  hemor- 
rhage are  generally  made  of  strips  of  bichloride,  iodo- 
form or  sterilized  gauze.  In  applying  these,  the  strips  of 
gauze  are  packed  into  the  cavity,  and  when  the  latter  is 
full  a  compress  is  applied  superficially  and  held  in  place 
by  a  bandage.  The  application  of  a  tampon  to  the  vagina 
is  a  favorite  method  of  controlling  uterine  hemorrhage. 

Glycerin  Tampon. — This  is  made  by  pouring  half  an 
ounce  of  glycerin  on  a  piece  of  cotton  or  wool,  and  then 
turning  up  the  ends  and  securing  them  by  a  string,  one 
end  of  which  is  allowed  to  remain  long  enough  to  hang 
from  the  vagina,  to  facilitate  its  removal ;  it  is  a  favorite 
application  to  the  os  uteri. 

Tent. — This  consists  of  a  small  portion  of  lint,  oakum, 
muslin,  or  sterilized  or  antiseptic  gauze  rolled  into  a  coni- 
cal shape,  which  is  employed  to  keep  wounds  open  and  to 
facilitate  the  escape  of  discharges. 


RETRACTORS. 


L69 


Retractors. — Retractors  are  made  by  taking  a  piece  of 
muslin  four  inches  wide  and  twelve  to  eighteen  inches  in 
length,  and  splitting  it  as  far  as  the  centre,  thus  making  a 
two-tailed  retractor  (Fig.  124).  A  three-tailed  retractor  is 
made  in  the  same  way,  except  that  the  muslin  is  slit  twice 
instead  of  once  (Fig.  125).  Retractors  are  used  to  retract 
the  soft  parts  in  amputations,  to  prevent  their  injury  by 


Fig.  124. 


Fig.  125. 


Two-tailed  retractor. 


Three-tailed  retractor. 


the  saw  in  the  division  of  the  bones.  When  one  bone 
is  sawed  a  two-tailed  retractor  is  used,  and  when  two 
bones  are  sawed  a  three-tailed  retractor  is  employed. 

Plasters. — The  varieties  of  plaster  which  are  most 
commonly  employed  in  surgical  dressings  are  adhesive  or 
resin  plaster,  isinglass  plaster,  and  rubber  adhesive  plaster. 

Before  using  any  of  these  plasters  upon  parts  which  are 


170  MINOR  SURGERY. 

covered  by  hairs,  the  latter  should  be  removed  by  shaving, 
otherwise  traction  upon  them,  if  the  plaster  be  used  for 
the  purpose  of  extension,  will  cause  the  patient  discom- 
fort, and  unnecessary  pain  will  also  be  inflicted  at  the  time 
of  its  removal. 

Resin  Plaster. — This  plaster,  which  is  machine-spread, 
is  one  of  the  most  widely  employed  plasters  in  surgical 
dressings ;  the  spread  surface  is  covered  with  a  layer  of 
tissue-paper,  which  should  be  removed  before  it  is  used  ; 
it  is  cut  into  strips  of  the  required  width  and  length,  and 
the  strips  should  be  cut  lengthwise  from  the  roll  of  plas- 
ter, as  the  cloth  upon  which  it  is  spread  stretches  more 
transversely  than  in  a  longitudinal  direction.  When 
heated  and  applied  to  the  surface  it  holds  firmly ;  it  is 
prepared  for  application  by  applying  the  unspread  side  to 
a  vessel  containing  hot  water,  or  it  may  be  passed  rapidly 
through  the  flame  of  an  alcohol  lamp. 

This  is  the  variety  of  plaster  which  is  generally  used  in 
making  the  extension-apparatus  for  the  treatment  of  fract- 
ures, for  strapping  the  chest  in  fractures  of  the  ribs  and 
sternum,  for  strapping  the  pelvis  in  cases  of  fractures  of 
the  pelvic  bones,  and  for  strapping  the  breast,  the  testicle, 
ulcers,  or  joints. 

Swans'-down  Plaster. — This  plaster  is  much  the  same  as 
resin  plaster,  but  is  spread  upon  a  heavier  material,  and 
is  an  excellent  plaster  to  use  for  an  extension-apparatus, 
where  it  is  to  be  worn  for  a  long  time. 

Rubber  Adhesive  Plaster. — This  plaster  is  made  by 
spreading  a  preparation  of  India-rubber  on  muslin,  and 
has  the  advantage  over  the  ordinary  resin  plaster  that  it 
adheres  without  the  application  of  heat.  It  is  employed 
for  the  same  purpose  as  resin  plaster,  but  when  applied 
continuously  to  the  skin  it  is  apt  to  produce  a  certain 
amount  of  irritation,  and  for  this  reason  when  it  is  to  be 
applied  for  some  time,  as  in  the  case  of  an  extension- 
apparatus,  it  is  not  so  comfortable  a  dressing  as  that 
made  from  resin  plaster. 

Zinc  Oxide  Adhesive  Plaster. — This  plaster  is  prepared  by 
incorporating  with  rubber  adhesive  plaster  oxide  of  zinc. 


STRAPPING.  171 

It  is  equally  as  adhesive  as  the  rubber  plaster,  and  pos- 
sesses the  advantage  that  it  is  not  apt  to  produce  irritation 
of  the  skin.  It  is  used  for  the  same  purposes  as  the 
rubber  adhesive  plaster. 

Isinglass  Plaster. — This  plaster  is  made  by  spreading  a 
solution  of  isinglass  upon  silk  or  muslin,  and  it  has  been 
found  a  most  useful  dressing  in  the  treatment  of  superficial 
wounds.  It  is  caused  to  adhere  to  the  surface  by  moisten- 
ing it,  and  when  used  in  the  treatment  of  wounds  it  should 
be  moistened  with  an  antiseptic  solution.  The  best  variety 
is  spread  on  muslin,  and  when  properly  applied  adheres  as 
firmly  and  possesses  as  much  strength  as  the  ordinary  resin 
plaster. 

Soap  Plaster. — Soap  plaster  for  surgical  purposes  is 
prepared  by  spreading  em/plastrum  saponis  upon  kid  or 
chamois  skin.  It  is  not  employed  for  the  same  purposes 
as  the  resin  or  rubber  plaster,  as  it  has  little  adhesive 
power,  and  is  used  simply  to  give  support  to  parts  or  to 
protect  salient  portions  of  the  skeleton  from  pressure.  It 
is  found  to  be  a  most  useful  dressing  when  applied  over 
the  sacrum  in  cases  of  threatened  bedsores,  and  may  be 
applied  for  the  same  purpose  to  other  parts  of  the  body 
where  pressure-sores  are  apt  to  occur. 

In  the  treatment  of  sprains  of  joints,  a  well-moulded 
soap-plaster  splint  secured  by  a  bandage  will  often  be 
found  a  most  efficient  dressing,  and  in  the  treatment  of 
fractures  the  comfort  of  the  patient  is  often  materially 
increased  by  applying  small  pieces  of  soap  plaster  over 
the  bony  prominences,  upon  which  the  splints,  even  when 
well  padded,  are  apt  to  make  an  undue  amount  of  pressure. 


STRAPPING. 

This  consists  in  applying  pressure  to  parts  by  means 
of  strips  of  plaster  firmly  applied  ;  it  is  a  procedure  often 
employed  in  surgical  practice. 

Strapping  the  Testicle. — In  strapping  the  testicle, 
strips  of  resin  plaster  are  usually  employed ;  a  dozen  or 


172 


MINOR  SURGERY. 


more  strips  one-half  an  inch  wide  and  twelve  inches  in 
length  will  be  required. 

The  scrotum  should  first  be  washed  and  shaved,  and  the 
surgeon  next  draws  the  skin  over  the  affected  organ  tense 
by  passing  the  thumb  and  finger  around  the  scrotum  at 
its  upper  portion,  making  circular  constriction  ;  a  strip  of 
muslin  is  passed  in  a  circular  manner  around  the  skin  of 
the  scrotum  above  the  organ,  and  is  tightly  drawn  and 
secured  by  passing  around  it  a  strap  of  plaster  which  has 
been  heated ;  this  isolates  the  part  and  prevents  the  other 
straps  from  slipping.  Straps  are  now  applied  in  a  longi- 
tudinal direction,  the  first  strap  being  fastened  to  the 
circular  strap  and  carried  over  the  most  prominent  part 
of  the  testicle,  and  then  carried  back  to  the  circular  strap 


Fig.  126. 


f£Sn. 


Strapping  the  testicle.    (Smith.) 

and  fastened.  A  number  of  these  straps  are  applied  in  an 
imbricated  manner  until  the  skin  is  covered  (Fig.  126), 
and  the  dressing  is  completed  by  passing  transverse  straps 
around  the  testicle  from  its  lowest  portion  to  the  circular 
strap  ;  care  should  be  taken  to  see  that  no  portion  of  the 
skin  is  left  uncovered. 

Strapping  the  testicle  is  employed  with  advantage  in  the 
subacute  stage  of  orchitis  or  epididymitis ;  as  the  swelling 
of  the  testicle  diminishes  the  straps  become  loose,  and  the 
part  will  require  re-strapping.  It  will  also  be  found  a 
useful  means  of  applying  pressure  to  the  scrotum  after  the 
injection-treatment  of  hydrocele. 

Strapping  of  the  Chest. — To  strap  one-half  of  the 
chest,  strips  of  resin  plaster  two  and  a  half  inches  wide, 


STRAPPING   OF   ULCERS. 


173 


Fig.  127. 


and  .sufficiently  long  to  extend  from  the  spine  to  the  me- 
dian line  of  the  sternum,  are  required — eighteen  to  twenty 
inches  in  length.  The  first  strap  is  heated,  and  one  ex- 
tremity is  placed  upon  the  spine  opposite  the  lower  portion 
of  the  chest ;  it  is  then  carried  over  the  chest,  and  its 
other  extremity  is  fixed  upon  the  skin  in  the  median  line 
of  the  sternum.  Straps  are  next  applied  from  below  up- 
ward in  the  same  manner,  each  strap  overlapping  one- 
third  of  the  preceding  one,  until  the  axillary  fold  is  reached 
(Fig.  127);  a  second  layer  of  straps  may  be  applied  over 
the  first,  if  additional  fixation  is  desired,  or  a  few  oblique 
straps  may  be  employed. 

Adhesive  straps  applied  in  this  manner  very  materially 
limit  the  motion  of  the  chest-wall  upon  the  affected  side, 
and  are  frequently  employed  in  the 
treatment  of  fractures  and  disloca- 
tions of  the  ribs,  in  contusions  of 
the  chest,  and  in  cases  of  plastic 
pleurisy  when  the  motions  of  the 
chest-wall  are  extremely  painful  to 
the  patient. 

Strapping  of  Ulcers. — To  strap 
ulcers  of  the  leg,  strips  of  resin 
plaster  one  and  a  half  inches  wide, 
and  sufficientlv  long  to  extend  two- 
thirds  of  the  distance  around  the 
limb,  are  required.  The  ulcer 
should  be  thoroughly  cleansed,  and  the  skin  surrounding 
it  well  dried ;  the  first  strap,  after  being  heated,  is  ap- 
plied transversely  to  the  long  axis  of  the  leg  about  two 
inches  below  the  ulcer,  and  is  carried  two-thirds  of  the 
distance  around  the  limb  ;  another  strap  is  applied  to  a 
corresponding  point  of  the  skin  above  this  one,  so  that  it 
overlaps  one-third  of  the  strap  first  applied,  and  it  is 
carried  two-thirds  of  the  way  around  the  limb.  Addi- 
tional straps  are  thus  applied  until  the  ulcer  is  covered  in, 
and  the  straps  are  carried  several  inches  above  the  ulcer 
(Fig.  128).  Strapping  of  ulcers  may  also  be  accomplished 
by  using  narrow  straps  of  plaster  one  and  a  half  inches  in 


Strapping  the  chest. 


174 


MINOR  SURGERY. 


width.  The  ends  of  two  straps  are  placed  upon  the  limb 
some  distance  below  the  ulcer,  and  the  straps  are  brought 
up  and  made  to  cross  each  other  so  as  to  draw  the  tissues 
toward    the    point  of  crossing ;  a   number  of  imbricated 


Fig.  128. 


Strapping  an  ulcer  of  the  leg. 


straps  are  applied  in  this  way  until  the  parts  are  suffi- 
ciently covered  in  and  supported  (Fig.  129).  Care  should 
be  taken  to  see  that  the  straps  are  so  applied  as  not  to 
meet  or  cover  the  entire  circumference  of  the  limb,  as  by 
so    doing    injurious   circular    compression    might    result. 


STRAPPING   OF   ULCEUS. 


175 


Chronic  ulcers  upon  other  portions  of  the  body  may  be 
strapped  in  the  same  manner. 

Strapping  of  leg  ulcers  is  usually  reinforced  by  the 
application  of  a  firmly  applied  spiral  reversed  or  spica- 
bandage  of  the  lower  extremity. 


Fig.  129. 


Strapping  an  ulcer  of  the  leg. 


Strapping  of  ulcers  of  the  leg  applied  in  the  manner 
described  will  be  found  a  most  satisfactory  method 
of  treating  chronic  ulcers  in  this  location  in  patients 
who  have  to  work  during  the  course  of  treatment ;  the 


176 


MINOR  SURGERY. 


straps  need  be  removed  only  at  intervals  of  a  week,  and 
if  well  applied,  the  dressing  is  generally  a  comfortable  one 
to  the  patient. 

Strapping  of  Joints. — Strips  of  resin  plaster  two 
inches  in  width  and  sufficiently  long  to  extend  two-thirds 
around  the  joint  are  required.  The  first  strap  is  applied 
a  few  inches  below  the  joint,  and  straps  are  then  applied 
over  this,  each  strap  covering  in  two-thirds  of  the  preced- 
ing one  until  the  joint  is  covered  in  and  the  dressing 
extends  a  few  inches  above  the  joint. 

Strapping  will  be  found  a  satisfactory  dressing  in  the 
treatment  of  sprains  of  joints  in  their  acute  or  chronic 
state. 

Fig.  130. 


Strapping  applied  to  ankle-joint. 


Strapping  the   Ankle-joint. -In   applying  strapping   in 
sprains   of  the   ankle-  or  tarsal  joints,  strips  of  rubber 


POULTICES.  177 

adhesive  plaster  one  and  a  half  inches  in  width  and  eigh- 
teen inches  in  length  are  required.  The  first  strap  is 
started  at  the  junction  of  the  middle  and  upper  part  of 
the  leg,  either  upon  the  inner  or  the  outer  side,  and 
applied  closely  to  the  edge  of  the  tendo  Achillis,  and  car- 
ried across  the  sole  of  the  foot  to  the  base  of  the  great  or 
little  toe  ;  several  of  these  straps  are  applied,  covering  in 
the  inner  or  enter  surface  of  the  ankle.  A  strap  is  next 
placed  with  its  middle  at  the  point  of  the  heel,  the  ends 
being  carried  to  a  point  on  the  foot  at  the  junction  of  the 
metatarsal  bones  and  the  tarsus;  a  number  of  these 
ascending  straps  are  applied,  alternating  with  the  vertical 
straps,  until  the  ankle-joint  is  covered  in.  These  straps 
should  not  be  applied  so  as  to  meet  in  front  of  the  foot  or 
ankle  and  make  circular  constriction  (Fig.  130).  After 
the  ankle  has  been  strapped  as  above  described,  the  foot 
and  ankle  are  covered  with  a  gauze  bandage,  and  the 
patient  is  allowed  to  walk  upon  the  injured  foot. 

Strapping  of  a  Carbuncle.— To  strap  a  carbuncle, 
strips  of  resin  plaster  one  to  one  and  a  half  inches  in  width 
are  required ;  these  straps  are  applied  at  the  margin  of 
the  swelling,  and  are  laid  on  concentrically  until  all  except 
the  central  portion  is  covered.  If  a  number  of  openings 
exist,  the  straps  are  so  placed  as  not  to  cover  these.  Strap- 
ping applied  in  this  manner  is  often  a  comfortable  dressing 
for  the  patient,  and  at  the  same  time  the  concentric  pressure 
favors  extrusion  of  the  slough. 


POULTICES. 

This  form  of  dressing  was  formerly  much  employed  in 
the  treatment  of  inflammatory  conditions  as  a  means  of 
applying  heat  and  moisture  to  the  part  at  the  same  time, 
and  'although  the  use  of  poultices  is  now  much  restricted 
since  the  introduction  of  the  antiseptic  method  of  wound 
treatment,  yet  I  think  there  are  still  conditions  in  which 
their  employment  is  both  useful  and  judicious.  They 
are  often  employed  with  advantage  in  inflammatory  affec- 
12 


178  MINOR  SURGERY. 

tions  of  the  chest  and  of  the  abdominal  organs ;  and  in 
inflammatory  affections  of  the  joints  and  of  bone,  com- 
bined with  rest,  their  action  is  often  most  satisfactory. 
They  constitute  a  form  of  dressing  which  is  conducive 
to  the  comfort  of  the  patient  in  cases  of  deep  suppura- 
tion by  their  relaxing  effect  upon  the  tissues,  and  their 
previous  use  does  not  prevent  the  surgeon  from  using  all 
aseptic  precautions  in  the  opening  and  drainage  of  these 
abscesses,  and  the  employment  of  aseptic  or  antiseptic 
dressings  in  their  subsequent  treatment. 

Flaxseed  Poultice. — This  poultice  is  prepared  by  add- 
ing first  a  little  cold  water  to  ground  flaxseed,  and  then 
boiling  and  stirring  it  until  the  resulting  mixture  is  of  the 
consistency  of  thick  mush.  A  piece  of  gauze  or  muslin  is 
next  taken  which  is  a  little  larger  than  the  intended  poul- 
tice, and  this  is  laid  upon  the  surface  of  a  table,  and  with 
a  spatula  or  knife  the  poultice-mass  is  spread  evenly  upon 
it  from  one-quarter  to  one-half  an  inch  in  thickness ;  a 
margin  of  the  muslin  of  one  or  one  and  a  half  inches  is 
left,  which  is  turned  over  after  the  poultice  is  spread,  and 
serves  to  prevent  it  from  escaping  around  the  edges  when 
applied.  The  surface  of  the  poultice  may  be  thinly  spread 
over  with  a  little  olive  oil,  or  may  be  covered  with  a  layer 
of  thin  gauze,  to  prevent  the  mass  from  adhering  to  the 
skin.  It  is  next  applied  to  the  surface  of  the  skin,  and  is 
covered  with  a  piece  of  oiled  silk,  rubber-tissue,  or  waxed 
paper,  and  held  in  position  by  a  bandage  or  a  binder. 

Soap  Poultice. — This  is  made  by  saturating  a  number 
of  layers  of  gauze  in  a  mixture  of  1  part  of  green  soap 
to  6  parts  of  water.  It  is  then  applied  to  the  surface 
and  covered  with  oiled  muslin  or  waxed  paper.  It  may  be 
employed  as  a  primary  dressing  for  some  hours  to  the  feet 
or  other  parts  of  the  body  where  the  epidermis  is  thick, 
before  sterilizing  these  parts  previous  to  operation. 

Starch  Poultice. — This  poultice  is  prepared  by  mixing 
starch  with  cold  water  until  a  smooth,  creamy  fluid  results  ; 
boiling  water  is  then  added,  and  it  is  heated  until  it  be- 
comes clear  and  attains  about  the  same  consistency  as  the 
starch  used  for  laundry  purposes.    When  sufficiently  cool, 


HOT  FOMENTATIONS.  179 

it  is  spread  upon  gauze  or  muslin,  applied  to  the  part,  and 
covered  with  oiled  silk  or  waxed   paper.     This  variety  of 
poultice  is   principally  useful  in  the  treatment  of  diseas 
of  the  skin,  especially  those  of  the  scalp  accompanied  by 

the  formation  of  scabs  or  crusts,  to  facilitate  their  removal 
and  to  afford  a  clean  surface  for  the  application  of  oint- 
ments or  wet  dressings. 

Fermenting-  Poultice. — This  poultice  maybe  prepared 
by  adding  yeast  (two  tablespoonfuls)  to  a  mixture  of  flax- 
seed with  hot  water,  making  a  thin  poultice-mass,  and 
allowing  it  to  stand  for  a  few  hours  in  a  warm  place ;  it 
rises  and  becomes  light,  and  is  then  spread  upon  gauze  or 
muslin  and  applied  as  reemired.  A  few  ounces  of  porter  or 
a  piece  of  yeast-cake  may  be  used  as  a  substitute  for  the 
yeast  in  preparing  this  poultice ;  animal  charcoal  may  also 
be  added  to  it  to  increase  its  .disinfectant  power.  This 
poultice  was  formerly  used  as  an  application  to  gangrenous 
parts  to  hasten  their  separation  and  to  diminish  the  odor 
arising  from  the  necrosed  tissues. 

Antiseptic  Poultice. — This  is  prepared  by  soaking  a 
pad  of  sterilized  gauze  in  hot  bichloride  or  carbolic  solu- 
tion and  wrincrino;  it  out  to  remove  the  excess  of  fluid.  It 
is  next  applied  to  the  part  and  covered  with  oiled  silk  or 
rubber-tissue,  which  may  be  held  in  place  by  a  bandage. 
Such  a  dressing  will  absorb  a  considerable  amount  of 
discharge. 

Hot  Fomentations. — Hot  fomentations  are  employed 
to  keep  up  the  vitality  of  parts  which  have  been  subjected 
to  injury,  as  seen  in  severe  contusions  resulting  from  rail- 
way or  machinery  accidents  ;  also  to  combat  inflammatory 
action.  Gauze  (several  layers  in  thickness)  or  surgical  lint 
should  be  soaked  in  sterilized  water  having  a  temperature 
of  120°  F. ;  these  are  wrung  out,  placed  over  the  part,  and 
covered  with  waxed  paper  or  rubber-tissue  ;  a  second  pad 
should  be  placed  in  the  hot  water,  and  applied  as  soon 
as  the  first-applied  cloth  begins  to  cool,  and  so  by  contin- 
uously reapplying  them  the  part  is  kept  constantly  covered 
by  a  hot  dressing.  The  use  of  these  hot  fomentations  may 
in  many  cases  require  to  be  continued  for  hours  before  the 


180  MINOR  SURGERY. 

desired  result  is  obtained.  Hot  compresses  applied  in  this 
manner  are  frequently  employed  in  treating  inflammatory 
conditions  of  the  eye,  and  are  also  of  the  greatest  service 
in  keeping  up  the  vitality  of  parts  which  have  been  sub- 
jected to  severe  injury  interfering  with  their  blood-supply. 
I  have  seen  contused  limbs,  which  were  cold  and  seemed 
doomed  to  gangrene  by  reason  of  diminished  blood-supply, 
have  their  temperature  and  circulation  restored  by  the 
patient  and  persistent  use  of  this  dressing.  After  the 
vitality  of  such  a  part  is  restored,  it  should  be  covered 
with  cotton  and  a  flannel  bandage  and  surrounded  by  hot- 
water  bags  or  hot-water  cans. 


IRRIGATION. 

This  may  be  accomplished  by  allowing  the  irrigating 
fluid  to  come  in  contact  with  the  wound  or  inflamed  part 
— immediate  irrigation  ;  or  by  allowing  the  cold  or  warm 
fluid  to  pass  through  rubber  tubes  which  are  in  contact 
with  or  surround  the  part — mediate  irrigation. 

Immediate  Irrigation. — In  employing  immediate  irri- 
gation in  the  treatment  of  wounds  or  inflammatory  condi- 
tions, a  funnel-shaped  can  with  a  stop-cock  at  the  bottom, 
or  a  bucket,  is  suspended  over  the  part  at  a  distance  of  a 
few  inches  (Fig.  131),  or  a  jar  with  a  skein  of  thread  or 
lamp-wick  arranged  to  act  as  a  siphon  may  be  employed 
(Fig.  132).  The  can  or  jar  is  filled  with  water,  and  this 
is  allowed  to  fall  drop  by  drop  upon  the  part  to  be  irri- 
gated, which  should  be  placed  upon  a  piece  of  rubber 
sheeting  so  arranged  as  to  allow  the  water  to  run  off  into 
a  receptacle,  to  prevent  wetting  the  patient's  bed.  The 
water  employed  may  be  either  cold  or  warm,  in  accord- 
ance with  the  indications  in  special  cases.  If  it  is  desired 
to  make  use  of  antiseptic  irrigation,  the  water  is  impreg- 
nated with  carbolic  acid  or  bichloride  of  mercury ;  a 
1  :  5000  to  1  :  10,000  bichloride  solution,  or  a  1  :  60  car- 
bolic acid  or  acetate  of  aluminum  solution,  being  frequently 
employed  with  good  results. 


IRRIGA  TION. 


181 


Antiseptic  irrigation  employed  in  this  manner  will  he 
found  a  most  useful  method  of  treating  lacerated  and  con- 
tused wounds  of  the  extremities  in  which  the  vitality  of 
the  tissues  is  much  impaired  ;  in  such  cases  water  at  a 


Fig.  131. 


Apparatus  for  continuous  irrigation.    (Esmarch.) 

temperature  of  100°  to  110°  F.,  should  be  preferred  to 
cool  water. 

Under  the  use  of  warm  irrigation  it  is  sometimes  sur- 
prising to  see  tissues  apparently  devitalized  regain  their 
vitality  in  a  short  time ;  the  absence  of  tension  from  the 
non-introduction  of  sutures  and  firm  dressings,  and  the 
warmth  and  moisture  kept  constantly  in  contact  with  the 


182 


MINOR  SURGERY. 


wound  by  this  method   of  irrigation,   are  the  important 
factors  in  the  attainment  of  this  favorable  result. 


Fig.  132. 


Irrigating-apparatus.    (Ekichsen.) 

Mediate  Irrigation. — In  this  method  of  irrigation  cold 
or  warmth  is  applied  to  the  surface  by  means  of  cold  or 
warm  water  passing  through  a  rubber  tube  in  contact  with 
the  part.  A  flexible  tube  of  India-rubber  half  an  inch  in 
diameter,  with  thin  walls,  and  sixteen  or  twenty  feet  in 
length,  is  applied  to  the  limb  like  a  spiral  bandage,  or  is 
applied  in  a  coil  to  the  head,  breast,  or  joints,  and  held  in 
place  by  a  few  turns  of  a  bandage  ;  the  end  of  the  tube  is 
attached  to  a  reservoir  filled  with  cold  or  warm  water 
above  the  level  of  the  patient's  body,  and  the  water  is 
allowed  to  flow  constantly  through  the  tubing  and  escape 
into  a  receptacle  arranged  to  receive  it  (Fig.  133). 

Cold-water  Dressings. — These  dressings  are  applied 
by  bringing  the  cold  water  either  directly  in  contact  with 
the  part  or  by  applying  it  by  means  of  a  rubber  bag  or 
bladder.  The  temperature  of  the  water  may  vary  from 
cool  water  to  that  of  ice-water. 

These  dressings  are  employed  in  local  inflammatory 
conditions.    A  favorite  method  for  the  employment  of  this 


IRRIGATION. 


183 


dressing  is  by  means  of  cold  compresses,  which  are  made 
of  a  few  layers  of  gauze  or  surgical  lint,  dipped  in  water 
of  the  desired  temperature  and  applied  to  the  part ;  they 
are  renewed  as  soon  as  they  become  warm.  When  it  is 
desirable  to  have  the  compresses  very  cold,  they  may  be 
laid  upon  a  block  of  ice  or  in  a  basin  with  broken  ice ; 
to  obtain  the  best  results  from  their  employment,  they 
should  be  renewed  at  very  short  intervals. 

Fig.  133. 


Cold  coil  applied  to  arm.    (Esmarch.) 

Ice-bag. — A  convenient  method  of  applying  cold  with- 
out moisture  is  by  the  use  of  the  ice-bag.  This  is  either 
a  rubber  bag  or  bladder,  which  is  filled  with  broken  ice 
and  applied  to  the  part.  In  using  an  ice-bag,  it  is  better 
to  cover  the  part  first  with  a  towel  or  a  few  layers  of  lint 
or  gauze,  which  prevent  the  surface  from  becoming  wet 
by  absorbing  the  moisture  which  condenses  upon  the  sur- 
face of  the  bag  or  bladder,  and  thus  renders  the  dressing 
more  comfortable  to  the  patient,  The  ice-bag  is  often 
employed  as  an  application  to  the  head  in  inflammatory 


184  MINOR  SURGERY. 

conditions  of  the  brain  or  membranes ;  to  the  abdomen  in 
cases  of  appendicitis,  and  is  used  also  upon  the  surface  of 
the  body  to  control  internal  hemorrhage. 


COUNTER-IRRITATION. 

Counter-irritants  are  substances  employed  to  excite 
external  irritation,  and  the  extent  of  their  action  varies 
according  to  the  material  used  and  the  duration  of  their 
application  ;  superficial  redness  or  complete  destruction 
of  the  vitality  of  the  parts  to  which  they  are  applied  may 
result. 

The  use  of  counter-irritants  under  favorable  circum- 
stances is  found  to  have  a  decided  effect  in  modifying 
morbid  processes,  and  they  are  widely  employed  as  local 
revulsants  in  cases  of  congestion  or  inflammation,  and  in 
cases  of  collapse  for  their  stimulating  effect. 

Caution  should  be  exercised  in  applying  counter-irri- 
tants to  patients  who  are  comatose  or  under  the  influence 
of  a  narcotic,  for  here  the  sensations  of  a  patient  cannot 
be  used  as  a  guide  to  their  removal,  and  their  too  long- 
continued  application  when  the  vitality  of  the  tissues  is 
impaired  may  result  in  serious  consequences. 

Rubefacients. — These  agents,  by  reason  of  their  irri- 
tating properties  when  applied  to  the  skin,  produce 
intense  redness  and  congestion. 

Hot  Water. — When  it  is  desired  to  make  a  prompt 
impression  upon  the  skin,  the  application  of  gauze,  muslin, 
or  flannel  cloths,  wrung  out  in  hot  water  and  renewed  as 
rapidly  as  they  become  cool,  will  soon  produce  a  super- 
ficial redness  of  the  integument. 

Spirit  of  Turpentine. — This  drug  applied  to  the  skin  is 
a  very  active  counter-irritant ;  it  may  be  rubbed  upon  the 
surface  until  redness  results.  When  used  upon  patients 
whose  skin  is  very  delicate,  its  action  may  be  modified  by 
mixing  it  with  an  equal  part  of  olive  oil  before  applying 
it;  this  combination  will  be  found  useful  as  a  rubefacient 
to  the  tender  skin  of  young  children. 


CO  UNTER-IRB1TA  TIOK  1 85 

When  redness  of  the  skin  has  resulted  from  the  appli- 
cation the  skin  should  he  wiped  dry  by  means  of  a  soft 
t«.\\cl  or  absorbent  cotton,  to  remove  any  turpentine  from 
the  surface,  which  by  its  continued  contact  may  cause 
vesication. 

Turpentine  Stupe. — This  is  prepared  by  sprinkling 
spirit  of  turpentine  over  flannel  cloths  which  have  been 
wrung  out  in  hot  water,  or  by  dipping  hot  flannel  in  warm 
spirit  of  turpentine  :  prepared  in  either  way,  the  stupe 
should  be  squeezed  as  dry  as  possible  to  remove  the  excess 
of  turpentine  before  being  applied  to  the  surface  of  the 
body.  A  turpentine  stupe  may  cause  vesication  if  allowed 
to  remain  for  too  long  a  time  in  contact  with  the  skin  ;  its 
application  for  from  five  to  ten  minutes  will  usually  pro- 
duce the  desired  effect ;  it  should  be  removed  after  this 
time,  and  it  may  be  reapplied  if  desired. 

If  the  patient  complains  of  severe  burning  of  the  skin 
after  the  use  of  turpentine,  the  painful  surface  should  be 
smeared  freely  with  vaseline  or  lard,  which  will  relieve 
the  uncomfortable  sensation. 

Tincture  of  Iodine. — This  drug  is  frequently  used  as  a 
counter-irritant  in  chronic  inflammation.  It  is  painted 
upon  the  part  at  intervals  until  irritation  of  the  skin  is 
observed,  when  its  use  is  discontinued  for  a  few  days 
before  reapplying  the  application. 

Chloroform. — A  few  drops  of  chloroform  applied  to  the 
surface  of  the  body  by  means  of  a  piece  of  lint,  muslin, 
or  flannel,  and  covered  by  oiled  silk  or  rubber-tissue,  will 
excite  a  rapid  rubefacient  effect. 

Mustard.— Ground  mustard  or  mustard  flour,  prepared 
from  either  Sinapis  alba  or  Sinapis  nigra,  is  one  of  the 
most  commonly  used  substances  to  produce  rubefacient 
action.  It  is  generally  employed  in  the  form  of  the  mus- 
tard plaster  or  sinapism,  which  is  prepared  by  mixing 
equal  parts  of  mustard  flour  with  wheat  flour  or  flaxseed 
meal,  and  adding  to  this  sufficient  warm  water  to  make  a 
thick  paste ;  this'is  spread  upon  a  piece  of  old  muslin,  and 
the  surface  of  the  paste  covered  with  some  thin  material, 
such  as  gauze,  to  prevent  the  paste  from  adhering  to  the 


186  MINOR  SURGERY. 

skin.  In  making  a  mustard  plaster  for  application  to  the 
skin  of  a  child,  1  part  of  mustard  flour  should  be  mixed 
with  3  parts  of  wheat  flour  or  flaxseed  meal. 

A  mustard  plaster  or  sinapism  may  be  allowed  to 
remain  in  contact  with  the  skin  for  a  period  varying  from 
fifteen  to  thirty  minutes,  the  time  being  governed  by  the 
sensations  of  the  patient ;  if  it  is  allowed  to  remain  longer, 
it  may  cause  vesication,  which  is  to  be  avoided,  as  ulcers 
produced  by  mustard  are  very  painful  and  extremely  slow 
in  healing.  After  removing  a  sinapism,  the  irritated  sur- 
face of  the  skin  should  be  dressed  with  a  piece  of  muslin 
or  lint  spread  with  vaseline,  boric  acid  or  oxide  of  zinc 
ointment. 

To  excite  a  rapid  revulsive  action,  the  mustard  foot-bath 
is  often  employed ;  it  is  prepared  by  adding  two  or  three 
tablespoonfuls  of  mustard  flour  to  a  bucket  or  foot-tub 
of  water  at  a  temperature  of  100°  to  110°  F. ;  in  this  the 
patient  is  allowed  to  soak  his  feet  for  a  few  minutes. 

Mustard  Papers. —  Chartce  Sinapis,  which  can  be 
obtained  in  the  shops  ready  for  use,  are  a  convenient 
means  of  obtaining  the  rubefacient  action  of  mustard. 
They  are  dipped  in  warm  water,  and  as  they  are  generally 
very  strong,  it  is  well  to  place  a  layer  of  muslin  between 
the  surface  of  the  plaster  and  the  skin  before  applying  it 
to  the  latter. 

Capsicum. — This  is  also  sometimes  employed  alone  as  a 
rubefacient,  but  it  is  generally  used  in  combination  with 
spices,  forming  the  well-known  spice  plaster  ;  this  is  pre- 
pared by  taking  equal  parts  of  ground  ginger,  cloves, 
cinnamon,  and  allspice,  and  adding  to  them  one-fourth 
part  of  Cayenne  pepper ;  these  are  thoroughly  mixed, 
enclosed  in  a  flannel  bag,  and  evenly  distributed ;  a  few 
stitches  should  be  passed  through  the  bag  at  different 
points,  to  prevent  the  powder  from  shifting  its  position ; 
before  applying  it,  one  side  of  the  bag  should  be  wet 
with  warm  whiskey  or  alcohol.  Capsine  plasters  are  em- 
ployed also  to  obtain  the  rubefacient  effect  of  Cayenne 
pepper. 

Aqua  Ammonia. — This  may  also  be  employed  for  its 


CO  UNTEB-  IRRITA  TION.  1 8  7 

rubefacient  action.  A  piece  of  lint  saturated  with  the 
stronger  water  of  ammonia,  placed  upon  the  skin  and 
covered  with  waxed  paper,  and  allowed  to  remain  for  one 
or  two  minutes,  will  produce  a  marked   rubefacient  effect. 

Vesicants. — Where  it  is  desirable  to  make  a  more  per- 
manent counter-irritant  effect  than  that  produced  by 
rubefacients,  substances  are  employed  which  by  their 
action  on  the  skin  cause  an  effusion  of  serum,  or  of  serum 
and  lymph,  beneath  the  cuticle,  thus  giving  rise  to  vesi- 
cles or  blisters  ;  they  are  known  as  vesicants.  The  sub- 
stance most  commonly  employed  to  produce  vesication  is 
Cantharis,  or  Spanish  fly,  and  the  preparation  commonly 
used  is  the  Ceratum  cantharidis. 

Fly  Blister. — This  is  prepared  by  spreading  ceratum 
cantharidis  upon  adhesive  plaster,  leaving  a  margin  one- 
half  an  inch  in  width  uncovered,  which  will  adhere  to 
the  skin  and  hold  the  blister  in  position.  The  time 
required  for  a  fly  blister  to  produce  vesication  is  from  four 
to  six  hours ;  it  should  then  be  removed,  and  the  surface 
covered  with  a  flaxseed-meal  poultice  or  with  a  warm- 
water  dressing.  When  the  blister  or  vesicle  is  well  devel- 
oped, it  may  be  punctured  at  its  most  dependent  part 
to  allow  the  serum  to  escape,  and  it  should  be  dressed 
with  vaseline  or  boric  ointment.  If  for  any  reason  it  is 
desired  to  keep  up  continued  irritation  after  allowing  the 
serum  to  escape,  the  cuticle  should  be  cut  away  and  the 
raw  surface  should  be  dressed  with  some  stimulating 
material,  such  as  the  compound  resin  cerate. 

Cantharidal  Collodion. — This  may  be  employed  to  pro- 
duce vesication ;  it  is  applied  by  painting  several  layers 
upon  the  skin  with  a  brush  over  the  part  on  which  the 
blister  is  to  be  produced.  It  is  a  convenient  preparation 
to  use  when  the  patient  would  disturb  the  ordinary  blister, 
as  in  the  case  of  a  child  or  an  insane  patient,  or  where  the 
surface  is  so  irregular  that  the  ordinary  blister  cannot 
well  be  applied.  The  after-treatment  of  blisters  produced 
by  cantharidal  collodion  is  similar  to  that  described  above. 

Caution  should  be  observed  in  using  blisters  upon  the 
tender  skins  of  children  ;    if   employed,  they  should  be 


188  MINOR  SURGERY. 

allowed  to  remain  in  contact  with  the  skin  for  a  short 
time  only.  They  are  contraindicated  in  patients  in  whom 
the  vitality  of  the  tissues  is  depressed  by  adynamic  dis- 
eases, and  in  aged  persons. 

Strangury,  which  is  shown  by  frequent  and  painful  mic- 
turition, the  urine  often  containing  blood,  sometimes  occurs 
from  the  use  of  cantharidal  preparations  as  blisters.  This 
condition  should  be  treated  by  the  use  of  opium  and  bel- 
ladonna by  suppository,  demulcent  drinks,  and  warm  sitz- 
baths,  and  by  leeches  to  the  perineum  if  the  symptoms  are 
very  severe. 

To  avoid  the  development  of  strangury,  small  blisters 
should  be  employed,  and  they  should  not  be  allowed  to 
remain  too  long  in  contact  with  the  surface;  cantharidal 
preparations  should  not  be  employed  in  cases  where  renal 
or  vesical  irritation  has  existed  or  is  present.  Strangury 
may  also  be  avoided  by  incorporating  opium  and  camphor 
with  the  cantharidal  cerate. 

Aqua  Ammonia  Fortior  and  Chloroform. — These  drugs 
may  be  employed  to  produce  rapid  vesication,  a  few  drops 
being  placed  upon  the  surface  of  the  body  and  covered  by 
an  inverted  watch-glass  for  a  few  minutes ;  or  lint  satu- 
rated with  aqua  ammonia  or  chloroform  may  be  placed 
upon  the  skin  and  covered  with  waxed  paper  or  oiled  silk. 
Either  of  these  agents  applied  in  this  manner,  and  allowed 
to  remain  in  contact  with  the  skin  for  fifteen  minutes,  will 
produce  marked  vesication.  The  blisters  resulting  from 
these  agents  are  painful,  and  they  are  only  to  be  used 
where  a  rapid  result  is  desired. 

Seguin's  Method  of  Counter-irritation. — This  consists  in 
stroking  the  surface  of  the  skin  lightly  and  rapidly  with 
the  point  of  a  Paquelin  cautery  ;  the  lines  of  stroking  may 
be  made  at  right  angles  ;  the  application  is  practically  pain- 
less, but  a  very  decided  counter-irritant  effect  is  produced. 
It  is  employed  with  advantage  in  neuralgic  affections  of 
the  spine  and  joints,  and  in  cases  of  neuritis  of  superficial 
nerves. 

Acupuncture. — Counter-irritation  is  effected  by  this 
method  by  thrusting  steel  needles  deeply  into  the  subcu- 


ACTC. if.    CATTERY. 


189 


Fig.  L34. 


taneous  tissues.  The  needles  employed  should  be  of  steel, 
from  two  to  four  inches  in  length,  strong, 
highly  polished,  and  sharp-pointed,  and 
should  have  round  metallic  heads  or  be 
fixed  in  handles  (Fig.  134).  Before  being 
used,  they  should  be  immersed  for  a  few 
minutes  in  boiling  Mater  or  in  a  carbo- 
lized  solution,  to  sterilize  them  thoroughly. 
In  performing  the  operation  of  acupunct- 
ure, localities  containing  important  or- 
gans, large  bloodvessels,  the  joints  and 
viscera,  should  be  avoided.  When  in- 
troduced, the  needles  should  be  passed 
through  the  skin  with  a  rotary  motion, 
the  skin  being  rendered  tense  between  the 
thumb  and  fingers,  and  pushed  into  the 
deep-seated  structures.  They  are  allowed 
to  remain  in  position  for  a  few  moments, 
and  are  then  withdrawn,  the  skin  being 

Supported  by  the  thumb  and  fingers.  Acupuncture  needles. 

Acupuncture  has  been  found  of  service 
in    cases    of   deep-seated    neuralgia,   obstinate    rheumatic 
affections,  and  sciatica. 

Actual  Cautery. — This  method  of  counter-irritation  is 
accomplished  by  bringing  in  contact  with  the  skin  some 
metallic  substance  brought  to  a  high  degree  of  tempera- 
ture. This  constitutes  one  of  the  most  powerful  means  of 
counter-irritation  and  revulsion  ;  it  is  rapid  in  its  action, 
and  is  not  more  painful  than  some  of  the  slower  methods. 
The  cauteries  generally  employed  are  made  of  iron,  and 
are  fixed  in  handles  of  wood  or  other  non-conducting 
material,  and  have  their  extremities  fashioned  in  a  variety 
of  shapes  (Fig.  135).  The  irons  are  heated  by  placing 
their  extremities  in  an  ordinary  fire,  or  by  holding  them 
in  the  flame  of  a  spirit-lamp  until  they  are  heated  to  the 
desired  point,  either  a  white  or  a  dull-red  heat.  They  are 
then  applied  to  the  surface  of  the  skin  at  one  point,  or 
drawn  over  it  in  lines  either  parallel  to  or  crossing  one 
another.     The  intense  burning  which  follows  the  use  of 


190 


MINOR  SURGERY. 


the  cautery  may  be  allayed  by  placing  upon  the  cautery- 
marks  compresses  wrung  out  in  ice-water  or  saturated  with 
equal  parts  of  lime-water  and  sweet  oil. 

Where  the  ordinary  cautery  irons  are  not  at  hand,  a 
steel  knitting-needle  or  iron  poker  heated  in  the  flame  of 
a  spirit-lamp  or  in  a  fire  may  be  employed  with  equally 
satisfactory  results.  Where  the  cautery  iron  is  held  in 
contact  with  the  surface  for  some  time  to  make  a  deep 
burn,  the  pain  of  its  application  may  be  allayed  by  placing 
a  mixture  of  salt  and  cracked  ice  upon  the  spot  to  be  cau- 
terized, for  a  few  minutes  immediately  before  its  applica- 
tion.    The  cautery  iron  should  not  be  placed  over  the 

Fig.  135. 


Cautery  irons, 


skin  covering  salient  parts  of  the  skeleton  or  over  impor- 
tant organs. 

The  actual  cautery,  in  addition  to  its  use  in  producing 
counter-irritation  and  revulsion,  is  often  employed  to  con- 
trol hemorrhage  and  to  destroy  morbid  growths. 

Paquelin's  Thermo -cautery. — A  very  convenient  and 
efficient  means  of  using  the  thermo-cautery  is  the  appa- 
ratus of  Paquelin,  which  utilizes  the  property  of  heated 
platinum-sponge  to  become  incandescent  when  exposed 
to  the  vapor  of  benzole  or  rhigolene  (Fig.  136).  The 
cautery  is  prepared  for  use  by  attaching  the  gum  tube  to 
the  receiver  containing  benzole,  and  heating  the  platinum 
knife  or  button,  which  also  is  attached  to  the  benzole  re- 


PA  Q  UELIN'S  THERM O-CA  UTER  Y. 


191 


ceiver  by  a  rubber  tube,  in  the  flame  of  the  alcohol  lamp 
for  a  few  moments,  and  then  passing  the  vapor  of  benzole 
through  the  platinum-sponge,  which  is  enclosed  in  the 
knife  or  button,  by  compressing  the  rubber  bulb.  The 
point  may  be  brought  to  a  white  heat  or  only  to  a  dull- 
red  heat. 

This  form  of  cautery  may  be  employed  for  the  same 
purposes  as  is  that  previously  mentioned ;  its  great  advan- 

Fig.  136. 


Paquelin's  cautery. 


tage  consists  in  the  ease  with  which  it  can  be  prepared  for 
use.  The  knives  heated  to  a  dull-red  heat  will  be  found 
of  great  service  in  operating  upon  vascular  tumors,  where 
the  use  of  an  ordinary  knife  would  be  accompanied  by 
profuse  or  even  dangerous  hemorrhage.  Wounds  made 
by  the  actual  cautery  are  aseptic  wounds,  and  when  dusted 
with  an  antiseptic  powder  generally  heal  promptly  under 
the  scab  without  suppuration. 


192  MINOR  SURGERY. 


BLOODLETTING. 


This  procedure  is  often  resorted  to,  to  obtain  both  the 
local  and  the  general  effects  following  the  withdrawal  of 
blood  from  the  circulation.  Local  depletion  is  accom- 
plished by  means  of  some  one  of  the  following  procedures  : 
scarification,  pnnctxiration,  cupping,  and  leeching ;  and  gen- 
eral depletion  is  effected  by  means  of  venesection  or  by 
arteriotomy . 

Scarification. — Scarification  is  performed  by  making 
small  and  not  too  deep  incisions  into  an  inflamed  or  con- 
gested part  with  a  sharp-pointed  bistoury ;  the  incisions 
should  be  in  parallel  lines,  and  should  be  made  to  corre- 
spond to  the  long  axis  of  the  part,  and  care  should  be 
taken  in  making  them  to  avoid  wounding  superficial  veins 
and  nerves.  Incisions  thus  made  relieve  tension  by  allow- 
ing blood  and  serum  to  escape  from  the  engorged  capil- 
laries of  the  infiltrated  tissue  of  the  part.  Warm  fomen- 
tations applied  over  the  incisions  will  increase  and  keep 
up  the  flow  of  blood  and  serum.  Scarification  is  employed 
with  advantage  in  inflammatory  conditions  of  the  skin  and 
subcutaneous  cellular  tissue  and  in  acute  inflammatory 
swelling  or  oedema  of  the  mucous  membrane,  for  instance, 
of  the  conjunctiva,  and  in  acute  inflammation  of  the  ton- 
sils, tongue,  and  epiglottis  it  is  an  especially  valuable 
procedure. 

A  modification  of  scarification,  known  as  deep  incisions, 
is  practised  in  urinary  infiltration  to  establish  drainage 
and  to  relieve  the  tissues  of  the  contained  urine,  and  to 
prevent  sloughing ;  in  threatened  gangrene  and  phleg- 
monous erysipelas  the  same  procedure  is  adopted  to  relieve 
tension  by  permitting  of  the  escape  of  blood  and  serum, 
and  its  employment  is  often  followed  by  most  satisfactory 
results. 

Puncturation. — This  procedure  consists  in  making 
punctures  into  inflamed  tissues  with  the  point  of  a  sharp- 
pointed  bistoury,  which  should  not  extend  deeper  than 
the  subcutaneous  tissue;  it  is  an  operation  similar  in 
character  to  that  just  described,  its  object  being  to  relieve 


DRY  CUPPING. 


19:3 


Fig.  137 


tension  and  bring  about  depletion.  It  is  employed  in 
cases  similar  to  those  in  which  scarification  is  indicated, 
and  is  resorted  to  in  cases  of  diffuse  areolar  inflammation 
or  erysipelas. 

Cupping". — Cupping  is  a  convenient  method  of  employ- 
ing local  depletion  by  inviting  the  blood  from  the  deeper 
parts  to  the  surface  of  the  body.  Cupping  is  accomplished 
by  the  use  of  dry  or  wet  cups.  When  the  former  are  used, 
no  blood  is  abstracted,  and  the  derivative  action  only  is 
obtained  ;  when  wet  cups  are  employed,  there  is  an  actual 
abstraction  of  blood  or  local  depletion  as  well  as  the 
derivative  action. 

Dry  Cupping. — Dry  cups  as  ordinarily  applied  consist  of 
small  cup-shaped  glasses,  which  have  a  valve  and  stop- 
cock at  their  summit ;  these  are  placed  upon  the  skin  and 
an  air-pump  is  attached,  and  as  the  air  is  exhausted  in  the 
cup  the  congested  integument  is  seen  to  bulge  into  the 
cavity  of  the  cup.  When  the  exhaustion  is 
complete  the  stop-cock  is  turned  and  the  air- 
pump  is  disconnected,  the  cup  being  allowed 
to  remain  in  position  for  a  few  minutes,  and 
is  then  removed  by  turning  the  stop-cock  and 
allowing  air  again  to  enter  the  cup.  This 
procedure  is  repeated  until  a  sufficient  num- 
ber of  cups  have  been  applied  (Fig.  137). 

In  cases  of  emergency,  when  the  ordi- 
nary cupping-glasses  and  air-pump  are  not 
available,  a  very  satisfactory  substitute  may 
be  obtained  by  taking  a  wineglass  and  burn- 
ing in  it  a  little  roll  of  paper,  or  a  small 
piece  of  lint  or  paper  wet  with  alcohol, 
and  before  the  flame  is  extinguished  rap- 
idly inverting  it  upon  the  skin  ;  or  the  air 
may  be  exhausted  by  the  introduction,  for 
a  moment  or  two,  of  the  flame  of  a  spirit- 
lamp  into  the  cup.  Applied  in  this  manner, 
cups  will  draw  as  well  as  when  the  more  com- 
plicated apparatus  is  used  ;  and  when  they  are 
to  be  removed,  it  is  only  necessary  to  press  the  finger  on 

13 


Cupping-glass 
and  air-pump. 


194 


MINOR  SURGERY. 


the  skin  close  to  the  edge  of  the  cup  until  air  enters  it, 
when  it  will  fall  off.  Although  dry  cups  do  not  remove 
blood  directly,  there  is  often  an  escape  of  blood  from  the 
capillaries  into  the  skin  and  cellular  tissue,  as  is  evidenced 
by  the  ecchymosis  which  frequently  remains  for  some  days 
at  the  seat  of  the  cup-marks. 

Wet  Cupping. — When  the  abstraction  of  blood  as  well 
as  the  derivative  action  is  desired,  wet  cups  are  resorted 
to,  and  here  it  is  necessary  to  have  a  scarificator  as  well  as 
the  cups  and  air-pump  (Fig.  138). 

Before  applying  wet  cups,  the  skin  should  be  washed 
carefully  w7ith   bichloride  or   carbolic   solution,  and   the 

Fig.  138. 


Scarificator. 


scarificator  should  also  be  sterilized  by  boiling.  A  cup 
is  first  applied  to  produce  superficial  congestion  of  the 
skin;  this  is  removed,  and  the  scarificator  is  applied  and 
the  skin  is  cut  by  springing  the  blades.  The  cups  are 
immediately  reapplied  and  exhausted,  and  they  are  kept 
in  place  as  long  as  blood  continues  to  flow.  When  the 
vacuum  is  exhausted  and  blood  ceases  to  flow,  they  should 
be  removed  and  emptied,  and  may  be  reapplied  if  it  is 
desirable  to  remove  more  blood.  A  sharp-pointed  bistoury 
which  has  been  sterilized  may  be  employed  to  make  a  few 
incisions  into  the  skin  instead  of  the  scarificator,  and  im- 
provised cups  may  be  employed  if  the  ordinary  cupping- 
apparatus  cannot  be  obtained. 

After    the    removal  of  wet  cups  the    skin    should    be 


LEECHING.  195 

washed  carefully  with  a  bichloride  or  carbolic  solution, 
and  an  antiseptic  dressing  should  be  placed  over  the 
wounds  and  held  in  place  by  a  roller-bandage. 

Leeching". — In  the  abstraction  of  blood  by  leeching, 
two  varieties  of  leeches  are  used — the  American  leech, 
which  draws  about  a  teaspoonful  of  blood,  and  the  Swedish 
leech,  which  draws  three  or  four  teaspoonfuls. 

Before  applying  leeches  the  skin  should  carefully  be 
washed,  and  the  leech  should  be  placed  upon  the  part 
from  which  the  blood  is  to  be  drawn,  and  confined  to 
this  place  by  inverting  a  tumbler  or  glass  jar  over  it ;  if  it 
does  not  bite  or  take  hold,  a  little  milk  or  blood  should  be 
smeared  upon  the  surface,  which  will  generally  secure  the 
desired  result.  As  soon  as  the  leech  has  ceased  to  draw 
blood  it  is  apt  to  let  go  its  hold  and  fall  off;  if,  however, 
it  is  desired  to  remove  leeches,  they  may  be  made  to  let  go 
their  hold  by  sprinkling  them  with  a  little  salt.  After  the 
removal  of  leeches  bleeding  from  the  bites  may  be  encour- 
aged, if  desirable,  by  the  application  of  warm  fomenta- 
tions. Leech-bites  should  be  washed  with  a  bichloride  or 
carbolic  solution,  and  a  compress  of  bichloride  or  iodoform 
gauze  placed  over  them  and  secured  by  a  bandage. 

It  sometimes  happens  that  free  bleeding  continues  from 
the  leech-bite  after  the  removal  of  the  leeches ;  in  this 
event,  if  a  compress  does  not  control  the  hemorrhage,  the 
bleeding  point  should  be  touched  with  a  stick  of  nitrate 
of  silver  or  with  the  point  of  a  steel  knitting-needle  heated 
to  a  dull-red  heat,  and  if  this  fails  to  control  the  bleeding 
a  delicate  harelip  pin  should  be  passed  through  the  skin 
under  the  bite  and  a  twisted  suture  thrown  around  this ; 
the  wound  should  then  be  washed  and  dressed  as  previously 
described. 

In  applving  leeches  in  or  near  the  mucous  cavities  care 
should  be  taken  to  see  that  they  do  not  escape  into  the 
cavities  and  pass  out  of  reach.  Leeches  should  not  be 
employed  directly  over  inflamed  tissue,  but  should  be  ap- 
plied to  parts  surrounding  it ;  they  should  not  be  allowed 
to  take  hold  directly  over  a  superficial  artery,  vein,  or 
nerve,  and  should  never  be  applied  to  a  part  where  there 


196 


MINOR  SURGERY. 


Fig.  139. 


are  delicate  skin  and  a  large  amount  of  loose  cellular  tissue, 
as  in  the  eyelid  or  scrotum,  as  unsightly 
ecchymoses  will  result,  which  persist  for 
some  time.  Leeches  should  not  be  used  a 
second  time. 

The  Mechanical  Leech. — The  mechanical 
leech  is  an  apparatus  which  has  been  con- 
structed to  take  the  place  of  the  leech ;  it 
consists  of  a  scarificator,  cup,  and  exhaust- 
ing syringe  or  air-pump  (Fig.  139).  In 
using  this  apparatus,  after  the  scarificator 
has  been  used  the  piston  of  the  exhausting- 
instrument  should  be  drawn  out  slowly, 
which  secures  a  better  flow  of  blood  than  if 
a  sudden  vacuum  is  created. 

The  mechanical  leech  may  be  employed 
when  the  natural  leech  cannot  be  obtained, 
but  possesses  no  advantage  over  the  latter, 
and  is  apt  to  get  out  of  order  if  not  in 
constant  use. 

Venesection. — Venesection,  as  its  name 
implies,  consists  in  the  division  of  a  vein, 
and  it  is  the  ordinary  operation  by  which 
general  depletion  or  bleeding  is  accomplished.  Vene- 
section at  the  bend  of  the  elbow  is  the  operation  which 
is  now  usually  resorted  to  for  general  bloodletting ;  the 
vein  selected  is  the  median  cephalic,  which  is  further 
from  the  line  of  the  brachial  artery  than  the  median 
basilic  vein  (Fig.  140). 

To  perform  venesection,  the  surgeon  requires  a  bistoury 
or  lancet — the  spring  lancet  was  formerly  much  used,  but 
it  is  not  employed  at  the  present  time — several  bandages, 
a  small  antiseptic  dressing,  and  a  basin  to  receive  the  blood. 
The  patient's  arm  should  carefully  be  cleansed,  washed 
over  with  a  bichloride  solution,  and  a  few  turns  of  a 
roller-bandage  placed  around  the  middle  of  the  arm, 
being  applied  tightly  enough  to  obstruct  the  venous  circu- 
lation and  make  the  veins  below  become  prominent,  but 
not  tight  enough  to  obstruct  the  arterial  circulation.     The 


Mechanical 
leech. 


VENESECTION.  197 

patient  at  the  same  time  should  be  instructed  to  grasp  a 
stick  or  a  roller-bandage  and  work  his  fingers  upon  it. 
The  surgeon  should  next  assure  himself  that  there  is  no 
abnormal  artery  beneath  the  skin,  and  having  selected 
the  vein,  the  median  cephalic  by  preference,  he  steadies 
it  with  the  thumb  and  passes  the  point  of  the  bistoury  or 
lancet  beneath  it  and  cuts  quickly  outward,  making  a  free 
skin  opening.  The  blood  usually  escapes  freely,  and  the 
amount  withdrawn  is  regulated  by  the  condition  of  the 
pulse  and  the  appearance  of  the  patient.  For  this  reason 
it  is  better  to  have  the  patient  sitting  up  or  semi-reclining 
when  venesection  is  performed,  as  the  surgeon  can  appre- 
ciate better  the  constitutional  effects  of  the  loss  of  blood 
while  the  patient  is  in  this  position. 

Fig.  140. 


Venesection.    (Heath.) 


When  a  sufficient  quantity  of  blood  has  been  removed, 
the  thumb  is  placed  over  the  wound  of  the  vein  and  the 
bandage  removed  from  the  arm  above.  The  wound  is  next 
washed  with  a  bichloride  solution,  and  a  compress  of  anti- 
septic gauze  is  applied  over  the  wound  and  held  in  posi- 
tion by  a  bandage,  which  should  be  so  applied  as  to  envelop 
the  limb  from  the  fingers  to  the  axilla.  The  dressing  need 
not  be  disturbed  for  five  or  six  days,  at  which  time  the 
wound  is  usually  found  to  be  healed. 

Wounds  of  the  brachial  artery  have  occurred  in  opening 
the  veins  at  the  bend  of  the  elbow,  but  if  care  is  taken, 
this  accident  should  not  take  place. 


198  MINOR  SURGERY. 

Venesection  may  be  practised  on  the  external  jugular 
vein  when,  from  excess  of  fat  or  in  the  case  of  children, 
the  veins  at  the  bend  of  the  elbow  cannot  be  easily  found. 
The  vein  is  rendered  prominent  by  placing  the  thumb  or 
a  pad  over  the  vein  at  the  outer  edge  of  the  stern  o-cleido- 
mastoid  muscle  just  above  the  clavicle.  The  vein  is  next 
opened  over  this  muscle  by  an  incision  parallel  to  its  fibres. 
After  a  sufficient  quantity  of  blood  has  escaped,  the  wound 
is  washed  with  an  antiseptic  solution  and  closed  by  a  com- 
press of  antiseptic  gauze  held  in  position  by  a  bandage 
carried  around  the  neck. 

The  internal  saphenous  vein  is  also  sometimes  selected  for 
venesection,  and  here  care  should  be  taken  not  to  wound 
the  accompanying  nerve  which  lies  directly  behind  the  vein. 

Arteriotomy. — This  operation  is  now  scarcely  ever  per- 
formed; but  if  done,  the  vessel  generally  selected  is  the 
anterior  branch  of  the  temporal  artery.  The  position  of 
the  vessel  is  fixed  by  the  finger  and  thumb,  and  it  is 
opened  by  a  transverse  incision  with  a  bistoury.  After  a 
sufficient  quantity  of  blood  has  escaped,  the  wound  is  in- 
spected, and  if  the  vessel  is  not  completely  divided,  its 
division  is  completed  and  the  ends  of  the  vessel  should  be 
secured  with  ligatures,  and  the  wound  irrigated  with  an 
antiseptic  solution  and  closed  with  sutures.  A  gauze 
compress  should  next  be  applied  and  held  in  position  by 
a  firmly  applied  bandage. 

Transfusion  of  Blood. — This  operation  may  be  em- 
ployed to  introduce  a  certain  quantity  of  blood  into  the 
circulation  of  a  patient  who  has  suffered  from  profuse 
hemorrhage ;  it  is  rarely  employed  at  the  present  time, 
being  almost  entirely  superseded  by  the  intravenous  in- 
jection or  infusion  of  saline  infusion.  There  are  two 
methods  by  which  transfusion  may  be  effected  :  the  direct, 
by  which  the  blood  is  conveyed  directly  and  without  ex- 
posure to  the  air  from  the  bloodvessel  of  one  person  to  that 
of  another ;  and  the  indirect,  in  which  the  blood  is  first 
drawn  from  one  person  and  is  then  injected  into  the 
veins  of  another,  being  deprived  of  its  fibrin  before  being 
injected. 


INJECTION  OF  SALINE  SOLUTION.  199 

Arterial  Transfusion. — This  procedure,  which  con- 
sists in  injecting  defibrinated  venous  blood  into  an  artery, 
is  occasionally  practised.  An  artery,  usually  the  radial  at 
the  wrist  or  the  posterior  tibial  behind  the  inner  mal- 
leolus, is  exposed  and  secured  by  a  ligature ;  it  is  then 
opened  on  the  distal  side  of  the  ligature,  and  the  point  of 
a  canula  or  the  nozzle  of  a  syringe  is  introduced,  directed 
toward  the  distal  extremity  of  the  limb,  and  blood,  which 
has  previously  been  defibrinated,  is  slowly  injected.  When 
a  sufficient  quantity  has  been  introduced,  the  canula  is 
removed,  the  division  of  the  artery  is  completed  and  its 
extremities  secured  by  ligatures,  and  the  wound  is  closed 
and  dressed. 

Auto -transfusion. — This  procedure  is  recommended  in 
cases  of  excessive  hemorrhage  to  support  a  moribund 
patient  until  other  means  of  resuscitation  can  be  adopted. 
It  consists  in  the  application  of  rubber  or  muslin  band- 
ages to  the  extremities  for  the  purpose  of  forcing  the 
blood  toward  the  vascular  and  nervous  centres. 


INTRAVENOUS  INJECTION  OF  SALINE  SOLUTION. 

It  has  been  proved  by  experiments  and  by  clinical 
experience  that  human  blood  is  not  more  efficacious  in 
supplying  volume  to  and  restoring  a  rapidly  failing  circu- 
lation than  normal  salt  solution,  and  as  the  latter  can  be 
obtained  with  much  more  ease  than  blood,  its  use  has 
largely  superseded  the  former.  The  solution  should  be 
at  a  temperature  of  110°  or  120°  F. 

A  vein  of  the  patient,  at  the  elbow,  should  be  exposed, 
and  should  have  placed  under  it,  about  one-half  inch 
apart,  two  catgut  ligatures ;  the  distal  ligature  is  then  tied 
and  an  opening  is  made  into  the  vein  between  the  liga- 
tures ;  a  canula  is  next  inserted  into  the  opening  in  the 
vein,  and  is  secured  in  position  by  tying  the  proximal 
ligature.  The  canula  is  first  filled  with  the  saline  solu- 
tion, and  is  then  connected  with  a  funnel  by  means  of  a 
rubber  tube  (Fig.  141),  which  is  filled  with  saline  solution 


200 


MINOR  SURGERY. 


to  displace  the  air,  and  upon  raising  the  funnel  above  the 
part  the  solution  enters  the  vein ;  care  should  be  taken  to 
see  that  the  funnel  is  kept  well  supplied  with  the  solution 
until  a  sufficient  quantity  has  been  introduced.  The 
quantity  introduced  is  regulated  by  the  condition  of  the 
patient's  pulse. 

Saline  solution  may  also  be  introduced  into  a  vein  by 

Fig.  141. 


Funnel  and  tube  for  intravenous  injection. 


means  of  a  syringe  when  the  apparatus  described  cannot 
be  obtained. 

Infusion  of   Saline   Solution — Hypodermoclysis. — 

The  introduction  of  saline  solution  into  the  cellular  tissue 
has  been  followed  by  results  equally  as  satisfactory  as  those 
obtained  by  intravenous  injection,  and  this  procedure  is 
now  very  frequently  employed. 

The  saline  solution  is  conveyed  into  the  cellular  tissue 
through  a  large  hypodermic  needle,  which  should  be  ster- 
ilized by  boiling,  and  is  then  introduced  into  the  connec- 
tive tissue,  being  previously  connected  by  a  rubber  tube 


ARTIFICIAL  RESPIRATION.  201 

with  a  reservoir  containing  warm  sterilized  salt  solution. 
The  usual  situations  for  the  introduction  of  the  solution 
are  the  external  portions  of  the  thighs  and  the  anterior 
and  lateral  portions  of  the  abdominal  walls.     As  much  as 

two  or  three  pints  of  the  solution  are  often  introduced  in 
this  manner,  with  very  satisfactory  results.  Infusion  of 
saline  solution  may  be  used  with  most  satisfactory  result- 
in  cases  who  have  suffered  from  profuse  hemorrhage,  and 
has  also  proved  of  great  service  in  cases  of  shock,  and 
has  a  distinct  value  in  the  treatment  of  septicaemia. 


ARTIFICIAL  RESPIRATION. 

This  procedure  is  resorted  to  in  cases  of  threatened 
death  from  apnoea  consequent  upon  drowning,  profound 
anesthetization,  electric  shock,  or  the  inhalation  of  irre- 
spirable  gases,  or  when  from  any  cause  there  is  interfer- 
ence with  the  function  of  breathing.  Before  resorting  to 
artificial  respiration,  care  should  be  taken  to  see  that 
nothing  is  present  in  the  mouth  or  air-passages  which  will 
obstruct  the  entrance  of  air  into  the  lungs,  such  as  mucus, 
foreign  bodies,  or  liquids,  and  also  that  all  tight  clothing 
interfering  with  the  free  expansion  of  the  chest-walls  is 
removed  from  the  chest. 

In  cases  where  the  apncea  is  due  to  the  presence  of  a 
foreign  body  in  the  larynx  or  trachea,  it  is  evident  that  no 
efforts  at  respiration  can  be  successful  until  the  air-pas- 
sages are  freed  from  the  occluding  body;  and  if  it  cannot 
be  removed  through  the  mouth,  tracheotomy  should  be 
performed  before  artificial  respiration  is  attempted  ;  the 
tracheal  wound  should  be  held  open  by  retractors,  which 
in  a  case  of  emergency  can  be  made  from  bent  hairpins. 
or  by  a  d re-sing*- forceps  or  a  tracheotomy-tube,  if  one  be 
at  hand. 

W  hen  artificial  respiration  is  resorted  to,  the  operator 
should  persevere  with  it  for  some  time,  even  when  no 
apparent  spontaneous  respiratory  movements  are  excited  ; 
for  resuscitation  has  been  accomplished  in  seemingly  hope- 


202  MINOR  SURGERY. 

less  cases  by  patient  perseverance  with  the  manipulations. 
When  the  first  natural  respiratory  movement  is  detected, 
the  operator  should  not  cease  making  artificial  respiration, 
but  should  continue  these  movements  in  such  a  way  as  to 
coincide  with  the  spontaneous  inspiratory  and  expiratory 
movements  until  the  breathing  has  assumed  its  regular 
character. 

The  temperature  of  the  body  should  also  be  restored  by 
friction  to  the  surface  by  the  hands  or  by  rough  towels 
and  hot-water  bottles,  and  warm  coverings  should  be 
applied  for  the  same  object. 

Mouth-to-mouth  Inflation. — This  method  of  artificial 
respiration  has  been  resorted  to  in  cases  of  great  emer- 
gency, especially  in  very  young  children.  The  operator 
draws  the  tongue  forward,  closes  the  nostrils,  and  applies 
his  mouth  directly  to  the  mouth  of  the  patient,  and  by  a 
deep  expiratory  eifort  endeavors  to  force  air  into  the  chest; 
when  this  is  accomplished,  the  air  can  be  expelled  from  the 
lungs  by  pressure  upon  the  walls  of  the  chest,  and  the 
procedure  should  be  repeated  about  sixteen  times  in  a 
minute.  The  same  object  may  be  accomplished  by  pass- 
ing a  flexible  catheter  into  the  trachea  through  the  mouth, 
and  the  lungs  can  be  inflated  by  the  operator  blowing  into 
the  catheter. 

Direct  Method  of  Artificial  Respiration  (Howard's). 
— This  method  of  artificial  respiration  is  at  the  present 
time  considered  the  most  efficacious,  and  is  the  one  adopted 
by  the  United  States  Life-saving  Service ;  and  although 
the  rules  given  are  for  the  resuscitation  of  cases  of  ap- 
parent drowning,  the  same  procedures  may  be  adopted  in 
cases  of  apncea  arising  from  other  causes. 

The  rules  laid  down  by  Dr.  Howard  are  as  follows  : 

Rule  I. — "  To  expel  water  from  the  stomach  and  lungs, 
strip  the  patient  to  the  waist,  and  if  the  jaws  are  clenched 
separate  them  and  keep  them  apart  by  placing  between  the 
teeth  a  cork  or  a  small  piece  of  wood.  Place  the  patient 
face  downward,  the  pit  of  the  stomach  being  raised  above 
the  level  of  the  mouth  by  a  roll  of  clothing  placed  beneath 
it  (Fig.  142).     Throw  your  weight  forcibly  two  or  three 


ARTIFICIAL    llKsl'IIlATIOS. 


•jn:i 


times  upon  the  patient's  back  over  the  roll  of  clothing, 
s<>  as  to  press  all  fluids  in  the  stomach  out  of  the  mouth." 


Fig.  142. 


First  manipulation  in  Howard's  method. 

The  first  rule  applies  only  to  cases  of  drowning,  and  in 
using  Howard's  method  in  apnoea  from  other  causes  it  is 

to  be  omitted. 

Ruh  II— "To  perform  artificial   respiration,  quickly 
turn  the  patient  upon  his  back,  placing  the  roll  of  clothing 
beneath  it  so  as  to  make  the  breast-bone  the  highest  point 
of  the  bodv.     Kneel  beside  or  astride  of  the  patient's  hips. 
Grasp  the  "front  part  of  the  chest  on  either  side  of  the  pit 
of  the  stomach,  resting  the  fingers  along  the  spaces  be- 
tween the  short  ribs.     Brace   your  elbows  against   your 
sides,  and  steadily  grasping  and  pressing  forward  and  up- 
ward throw  your  whole  weight  upon  the  chest,  gradually 
increasing  the  pressure  while  you  count  one — two — three. 
Then  suddenly  let  go  with  a  final  push  which  springs  you 
back  to  your"  first  position  (Fig.  143).     Rest  erect  upon 
your  knees  while  you  count  one — two;  then  make  press- 
lire  as  before,  repeating  the  entire  motions  at  first  about 
four  or  fiye  times  a  minute,  gradually   increasing  them 
to  about  ten  or  twelye  times.     Use  the  same  regularity 
as  in  blowing  bellows  and  as  seen  in  the  natural  breath- 


204 


MINOR  SURGERY. 


ing  which  you  are  imitating.  If  another  person  is  pres- 
ent, let  him  with  one  hand,  by  means  of  a  dry  piece  of 
linen,  hold  the  tip  of  the  tongue  out  of  one  corner  of  the 
mouth,  and  with  the  other  hand  grasp  both  wrists  and  pin 
them  to  the  ground  above  the  patient's  head."  This 
method  may  be  employed  in  cases  of  stillbirth,  or  in 
young  children,  the  operator  holding   the   body   of  the 

Fig.  143. 


Direct  method  of  artificial  respiration. 


child  in  his  left  hand  and  compressing  it  with  the  right 
hand. 
Silvester's  Method  of  Artificial  Respiration. — In 

employing  this  method  of  artificial  respiration  the  patient 
should  be  placed  on  his  back  upon  a  firm  flat  surface  ;  a 
cushion  of  clothing  is  placed  under  the  shoulders,  and  the 
head  should  be  dropped  lower  than  the  body  by  tilting 
the  surface  on  which  he  is  laid.  The  mouth  being  cleared 
of  mucus  or  foreign  substances,  the  tongue  is  drawn  for- 
ward and  secured  to  the  chin  by  a  piece  of  tape  tied 
around  it  and  the  lower  jaw,  or  may  be  pulled  out  of  the 
mouth  and  held  by  an  assistant.  The  operator,  standing 
at  the  patient's  head,  grasps  the  arms  at  the  elbows  and 
carries  them   first  outward  and  then  upward   until   the 


ARTIFICIAL  RESPIRATION. 


205 


Fig.  144. 


Silvester's  method— inspiration.    (Esmarch.) 


Fig.  145. 


Silvester's  method  -expiration.    (Esmarch. 


206  MINOR  SURGERY. 

hands  are  brought  together  above  the  head ;  this  repre- 
sents inspiration  (Fig.  144) ;  they  should  be  kept  in  this 
position  for  two  seconds,  after  which  time  they  are  brought 
slowly  back  to  the  sides  of  the  thorax  and  pressed  against 
it  for  two  seconds ;  this  represents  expiration  (Fig.  145). 
These  movements  are  repeated  fifteen  times  in  a  minute 
until  the  breathing  is  restored  or  it  is  evident  that  the 
case  is  a  hopeless  one. 

Laborde's  Method  of  Artificial  Respiration. — 
Laborde  has  shown  that  systematic  and  rhythmic  traction 
upon  the  tongue  is  a  powerful  means  of  restoring  the 
respiratory  reflex,  and  consequently  the  function  of  respi- 
ration. The  procedure  is  accomplished  as  follows  :  The 
body  of  the  tongue  is  seized  between  the  thumb  and 
fingers,  and  traction  is  made  upon  it  with  alternate  relaxa- 
tion, fifteen  or  twenty  times  a  minute,  imitating  the  func- 
tion of  respiration,  taking  care  to  draw  well  on  the  tongue. 
When  a  certain  amount  of  resistance  is  felt,  it  is  a  sign 
that  the  respiratory  function  is  being  restored.  Noisy 
respiration  first  occurs,  termed  by  Laborde  hoquet  inspira- 
teur  (inspiratory  hiccough).  Tongue  forceps  or  dressing 
or  haemostatic  forceps  may  be  used  in  place  of  the  fingers 
to  grasp  the  tongue.  It  is  important  to  persist  in  the 
manipulations  for  half  an  hour  to  an  hour,  unless  the  case 
is  absolutely  hopeless.  This  procedure,  which  cannot  be 
employed  with  advantage  when  there  is  fixation  of  the 
tongue  from  inflammation  or  malignant  disease,  has  been 
employed  with  success  in  cases  of  drowning,  toxic  asphyxia, 
asphyxia  during  anaesthesia,  and  arrest  of  respiration  from 
electric  shock. 

Forced  Respiration. — By  this  method  of  artificial 
respiration  air  is  forcibly  passed  into  the  lungs.  This 
procedure  is  strongly  advocated  by  Fell,  who  has  devised 
an  apparatus  by  which  it  may  be  satisfactorily  accom- 
plished. Professor  H.  C.  Wood  has  also  made  use  of 
forced  respiration  in  the  resuscitation  of  animals  with  an 
apparatus  somewhat  similar  to  that  devised  by  Fell,  with 
good  results.  Wood's  apparatus  consists  of  a  pair  of  bel- 
lows, a  few  feet  of  rubber  tubing  and  a  face-mask  of  rubber, 


FORCED  RESPIRATION. 


207 


and  one  or  two  intubation-tubes;  the  mask  or  intubation- 
tube  is  attached  to  one  end  of  the  rubber  tube  and  the 

bellows  to  the  other  extremity.  The  mask  is  applied 
over  the  mouth,  or,  if  this  is  not  used,  the  intubation-tube 
is  introduced  into  the  larynx,  and  air  is  forced  into  the 
lungs  by  working  the  bellows.  He  also  advises  that  in 
the  tubing  a  double  metal  tube  be  introduced,  with  the 
openings  so  placed  that  their  size  can  be  so  regulated  by 
turning  the  outer  tube  that  the  operator  can  allow  any 
excess  of  air  thrown  by  the  bellows  to  escape. 

Fig.  146. 


Fell's  ajjparatus  for  forced  respiration. 


The  apparatus  of  Fell,  which  he  has  used  in  a  number 
of  cases  with  good  results,  consists  of  a  mouth-mask  or 
tracheotomy-tube,  and  a  tube  connected  with  the  air-con- 
trol valve,  which  is  attached  to  an  air- warming  apparatus, 
which  in  turn  is  connected  with  a  bellows  by  another 
tube  (Fig.  146).  By  means  of  this  apparatus  air  is  forced 
into  the  lungs,  and  allowed  to  escape,  when  the  lungs 
have  been  expanded,  by  the  elasticity  of  the  lung  tissue 
and  the  chest  walls. 

Forced  respiration  has  proved  of  value  in  cases  of 
narcotic  poisoning  and  other  accidents  in  which  death  is 
produced  by  paralysis  of  the  respiratory  centres. 


208 


MINOR  SURGERY. 


Aspiration. — This  procedure  is  adopted  to  remove  fluid 
from  a  closed  cavity  without  the  admission  of  air,  and  the 
instrument  which  is  employed  to  accomplish  this  object  is 
known  as  an  aspirator.  The  form  of  aspirator  most 
generally  employed  is  that  of  Potain. 

Potain's  Aspirator. — This  consists  of  a  glass  bottle,  into 
the  stopper  of  which  is  introduced  a  metallic  tube,  which  is 
connected  with  two  rubber  tubes,  one  of  which  is  connected 
with  an  exhausting-pump,  and  the  other  with  a  delicate 

Fig.  147. 


Potain's  aspirator. 


canula  carrying  a  fine  trocar ;  the  apparatus  is  provided 
with  stop-cocks  to  prevent  the  admission  of  air  (Fig. 
147).  In  using  this  aspirator,  the  air  is  exhausted  from 
the  bottle  by  using  the  air-pump  ;  the  canula  enclosing  the 
trocar  is  next  pushed  through  the  tissues  into  the  cavity 
containing  the  fluid  to  be  removed  ;  the  trocar  is  then 
removed,  and  upon  opening  the  stop-cock  the  fluid  is 
forced  out  of  the  cavity  by  atmospheric  pressure  and 
passes  into  the  bottle  or  receiver.  If  the  fluid  contains 
masses  of  lymph  or  clots  which  block  the  canula,  inter- 


THE  STOMACH-TUBE.  209 

rupting  the  flow  of  fluid,  a  stylet  may  be  passed  through 
the  canula  to  free  it  from  the  obstruction. 

To  diminish  the  pain  produced  in  introducing  the  trocar 

and  canula,  the  skin  at  the  point  to  be  punctured  may  be 
rendered  less  sensitive  by  holding  in  contact  with  it  for  a 
few  minutes  a  piece  of  ice  wrapped  in  a  towel,  or  a  towel 
containing  broken  ice  and  salt.  Care  should  also  be  taken 
to  see  that  the  trocar  and  canula  have  been  perfectly  steril- 
ized ;  to  accomplish  this,  they  should  be  carefully  washed 
and  placed  in  boiling  water  or  a  5  per  cent,  carbolic  solu- 
tion before  being  used.  In  introducing  the  trocar  and 
canula,  the  operator  should  be  careful  to  avoid  injuring 
important  veins,  arteries,  or  nerves. 

After  removing  the  canula  the  small  puncture  should 
be  dressed  with  a  compress  of  antiseptic  or  iodoform  gauze, 
held  in  place  by  a  bandage  or  adhesive  straps. 

The  aspirator  is  frequently  employed  in  cases  of  hydro- 
thorax,  empyema,  and  ascites,  to  evacuate  the  contents  of 
cold  abscesses  in  diseases  of  the  hip  and  spine,  and  to 
remove  the  contents  of  a  distended  bladder  until  a  more 
radical  operation  can  be  performed.  It  is  also  a  valuable 
instrument  for  diagnostic  purposes,  being  frequently  used 
to  ascertain  the  character  of  the  contents  of  deep-seated 
tumors  containing  fluid. 

The  Stomach-tube. — This  consists  of  a  partially  flexi- 
ble tube  about  twenty-eight  inches  in  length  and  three- 
eighths  of  an  inch  in  diameter,  which  is  introduced  while 
the  patient  is  in  the  sitting  posture,  the  head  being  thrown 
backward  so  as  to  bring  the  mouth  and  gullet  as  nearly 
as  possible  in  the  same  line  (Fig.  148).  The  tube  being 
warmed  and  oiled,  the  surgeon  standing  in  front  of  the 
patient  passes  it  directly  back  to  the  pharynx,  at  the  same 
time  introducing  the  index-finger  of  the  left  hand  to  guide 
its  point  over  the  epiglottis ;  it  is  then  passed  gently 
downward  into  the  stomach.  If  any  obstruction  is  met 
with  in  its  passage,  it  should  be  withdrawn  a  little  and 
then  pushed  gently  downward  ;  all  manipulations  should 
be  made  without  much  force,  to  avoid  perforating  the  wall 
of  the  oesophagus, 
u 


210  MINOR  SURGERY. 

The  introduction  of  the  stomach-tube  may  be  required 
for  the  evacuation  of  poisons  from  the  stomach  or  to  wash 
out  the  cavity  of  this  viscus.  It  may  also  be  used  to  intro- 
duce liquid  nourishment  into  the  stomach  of  patients  who 
are  unable  or  unwilling  to  swallow  food.  In  introducing 
liquid  nourishment  a  syringe  or  funnel  is  fitted  to  the  free 
end  of  the  tube,  which  has  been  passed  into  the  stomach ; 
the  syringe  or  funnel  having  been  filled  with  milk  or  beef- 
tea  or  broth,  the  contents  are  injected  gently  or  allowed  to 
run  into  the  stomach. 

In  cases  of  poisoning,  where  it  is  desirable  to  withdraw 
the  contents  of  the  stomach  and  to  wash  out  the  organ,  a 
stomach-tube  and  syringe  may  be  employed ;  several 
syringefuls  of  warm  water  are  first  thrown  into  the 
stomach  and  then   withdrawn    by    suction,  but   in    such 

Fjg.  148. 


The  stomach-tube. 


cases  the  use  of  the  stomach-pump  will  be  found  more 
satisfactory. 

Lavage. — In  the  recently  introduced  method  of  treating 
disorders  of  the  stomach  and  intestines  by  washing  them 
out,  the  introduction  of  a  flexible  rubber  stomach-tube  is 
required ;  the  tube  here  employed  is  from  twenty-four  to 
thirty  inches  in  length,  and  the  fluid  is  introduced  by 
means  of  a  funnel  attached  to  its  free  extremity,  or  it 
may  be  attached  to  a  stomach-pump. 

The  Stomach-pump. — This  consists  of  a  brass  syringe, 
the  nozzle  of  which  is  connected  with  two  tubes,  one  at  the 
end,  the  other  at  the  side.  The  passage  of  fluid  through  the 
nozzle  is  regulated  by  a  valve  controlled  by  a  lever.  The 
nozzle  of  the  pump  is  attached  to  a  stomach-tube,  and  the 
end  of  the  lateral  tube  is  placed  in  a  pan  of  warm  water. 
By  withdrawing  the  piston  and  opening  the  valve,  water 
may  be  drawn  from  the  basin,  and  by  closing  the  valve 
and  depressing  the  piston  it  is  forced  through  the  stomach- 


(ESOPHAGEAL  BOUGIE. 


211 


tube  into  the  stomach  ;  when  a  sufficient  quantity  has  been 
injected  in  this  manner,  by  reversing  the  action  of  the 
valve  the  fluid  is  drawn  out  of  the  stomaeh  and  dis- 
charged through  the  lateral  tube  into  a  basin.  This 
manipulation  is  continued  until  the  water  returns  clear 
and  the  stomach  has  been  completely  washed  out.  The 
stomach-pump  shown  in  Fig.  149  may  also  be  employed. 

Fig.  149. 


Stomach-pump. 


(Esophageal  Bougie.— This  instrument— which  may  be 
passed  through  the  oesophagus  into  the  stomach  for  the 
purpose  of  diagnosis  or  for  the  purpose  of  dilating  strict- 
ures of  the  oesophagus — is  employed  in  exactly  the  same 
manner  as  the  stomach-tube,  and,  as  in  the  case  of  the 
latter  instrument,  it  should  be  introduced  without  the  use 
of  much  force,  as  perforations  of  the  oesophagus  have  fol- 
lowed the  forcible  introduction  of  such  instruments. 

The  Rectal  Tube.— The  introduction  of  the  rectal  tube 
is  best  accomplished  by  placing  the  patient  upon  his  left 
side,  and  the  surgeon  should  introduce  his  index  finger 
well  oiled  into  the  rectum  and  guide  the  tube  upon  this 
through  the  anus,  when  by  gentle  pressure  it  is  gradually 
passed  into  the  rectum  ;  if  a  stricture  exists  in  the  rectum 


212  MINOR  SURGERY. 

within  reacli  of  the  finger,  the  latter  should  be  used  to 
guide  the  tube  through  the  opening  in  this ;  if  the  tube 
becomes  caught  in  a  transverse  fold  of  the  mucous  mem- 
brane and  doubles  upon  itself,  it  should  be  withdrawn 
and  a  fresh  attempt  made  to  pass  it.  In  passing  a  rectal 
tube  all  manipulations  should  be  made  with  extreme 
gentleness,  as  it  has  been  shown  that  its  passage  is  not 
without  danger,  perforations  of  the  intestine  having  fol- 
lowed its  use  in  some  cases.  In  cases  of  stricture  of  the 
rectum  high  up,  the  operator  has  to  depend  upon  the 
sense  of  resistance  experienced  in  passing  the  tube,  and 
in  such  cases  the  manipulations  should  be  most  carefully 
made.  When  the  rectal  tube  is  employed  to  introduce 
fluid  into  the  large  intestine,  the  fluid  may  be  introduced 
by  means  of  a  syringe,  or  by  pouring  it  into  a  funnel 
attached  to  the  free  end  of  the  tube,  or  by  attaching  the 
tube  to  a  fountain  syringe,  thus  allowing  the  liquid  to  pass 
slowly  into  the  intestine. 

The  rectal  tube  is  often  employed  with  good  results  in 
relieving  the  intestine  of  excessive  flatus,  and  in  intro- 
ducing water  or  oil  into  the  intestine  in  cases  of  intestinal 
obstruction,  and  in  those  cases  where  the  obstruction  results 
from  intussusception  or  fecal  accumulations  its  use  will 
often  prove  satisfactory. 

Rectal  Bougies. — These  instruments  are  made  of  India- 
rubber  or  the  same  material  as  the  English  flexible  cathe- 
ter, and  are  of  various  sizes.  They  should  first  be  oiled, 
and  are  introduced  in  the  same  manner  as  the  rectal  tube. 
They  are  generally  employed  in  cases  of  stricture  of  the 
rectum,  and  should  be  introduced  with  great  care  to 
avoid  perforating  the  wall  of  the  rectum  ;  this  accident 
has  occurred  in  the  hands  of  skilful  surgeons.  A  very 
satisfactory  substitute  for  a  rectal  bougie  is  a  tallow  candle, 
one  end  of  which  is  melted  or  rubbed  down  to  a  conical 
shape. 

Enemata. — These  may  be  administered  by  means  of  an 
ordinary  syringe,  or  by  means  of  a  gravity  or  fountain 
syringe ;  the  precautions  which  should  be  observed  are  to 
introduce  the  nozzle  of  the  syringe  gently  and  in  the  right 


VACCINATION.  213 

direction,  as  perforation  of  the  lower  portion  of  the  rectum 
has  taken  place  from  careless  and  Forcible  introduction 
of  the  nozzle  of  the  enema-syringe ;  the  fluid  should  also 
be  injected  slowly,  as  by  so  doing  there  is  less  resistance 
and  less  tendency  for  the  patient  to  pass  the  fluid  before 
the  desired  quantity  has  been  introduced. 

The  enema  most  commonly  employed  to  empty  the  lower 
bowel  is  made  by  adding  a  tablespoonful  of  sweet  oil  and 
two  teaspoonfuls  of  spirit  of  turpentine  to  one  or  two 
pints  of  warm  water  in  which  a  little  Castile  soap  has  been 
dissolved ;  warm  water  and  sweet  oil  are  also  frequently 
used  for  the  same  purpose. 

Glycerin  Enema. — One  or  two  teaspoonfuls  of  glycerin 
injected  into  the  rectum,  or  a  suppository  made  of  glycerin, 
will  often  be  found  an  efficient  substitute  for  the  larger 
enemata  of  water. 

Nutritious  Enema. — When  it  is  found  necessary  to  resort 
to  feeding  by  the  rectum,  the  substances  employed  should 
be  injected  into  the  rectum  by  means  of  a  syringe,  and 
care  should  be  taken  that  the  quantity  is  not  too  large,  and 
that  it  is  of  such  a  nature  as  not  to  cause  irritation  of  the 
walls  of  the  rectum,  or  it  will  not  be  retained  ;  two  to  four 
ounces  in  the  case  of  an  adult  is  generally  a  sufficient 
quantity  to  inject  at  one  time. 

Peptonized  milk  or  beef-juice,  or  the  yolk  of  an  egg 
beaten  up  with  milk,  is  often  employed,  and  any  unirri- 
tating  drugs  may  be  mixed  with  the  enema  and  adminis- 
tered at  the  same  time. 

Vaccination. — This  is  a  minor  surgical  procedure  which 
every  physician  is  called  upon  to  perform.  The  surface 
may  be  prepared  for  the  reception  of  the  lymph  by  abrad- 
ing the  skin  at  one  or  two  points  with  a  dull  lancet,  or 
by  making  several  superficial  incisions  with  a  knife,  or 
by  scratching  the  surface  of  the  skin  with  the  ivory  point 
charged  with  lymph,  in  lines  with  crossing  lines,  cross- 
scratch,  until  a  little  serum  exudes.  It  is  not  advisable 
to  draw  blood,  which  washes  away  the  lymph,  and  for 
this  reason  we  prefer  the  abraded  surface  made  by  the  dull 
knife  or  the  ivory  point. 


214  MINOR  SURGERY. 

The  lymph  used  may  be  the  humanized  or  the  bovine. 

Bovine  lymph  or  virus,  which  is  now  most  generally  em- 
ployed, is  taken  from  the  vaccine  vesicles  upon  the  udders 
and  teats  of  heifers.  The  lymph  may  be  mixed  with  ster- 
ilized glycerin  and  placed  in  fine  glass  tubes,  which  are 
sealed  ;  or  ivory  points  or  quills  are  dipped  in  the  lymph 
and  allowed  to  dry,  and  in  using  these  they  are  dipped  in 
water  for  a  moment,  to  moisten  the  lymph,  before  being 
applied  to  the  abraded  surface.  The  ivory-point  is  one  of 
the  most  convenient  means  of  vaccination,  as  the  surface 
may  be  abraded  with  it  before  the  lymph  is  applied. 

It  has  recently  been  advised  that  antiseptic  precautions 
be  exercised  in  performing  vaccination,  and  although  all 
of  the  details  cannot  be  carried  out,  we  have  found  that 
the  exercise  of  care  as  regards  cleanliness  of  the  surface 
has  been  followed  by  much  fewer  inflammatory  complica- 
tions in  vaccination  wounds. 

The  surface  to  be  abraded,  usually  the  left  arm  below 
the  deltoid,  is  first  washed  with  soap  and  water,  then  with 
a  1  :  2000  bichloride  solution,  or  with  alcohol,  and  finally 
washed  with  sterilized  water.  Two  points  of  this  surface, 
an  inch  apart,  are  then  abraded  by  using  a  knife  which 
has  been  washed  or  dipped  in  boiling  water,  or  by  using 
the  ivory-point  which  has  been  dipped  in  water  that  has 
been  boiled  and  cooled.  When  the  surface  has  been  pre- 
pared in  the  manner  described,  the  moistened  virus  is 
rubbed  upon  it  and  allowed  to  dry.  Vaccination  upon 
the  leg,  which  is  practised  by  some  physicians  to  prevent 
the  scar  from  showing,  I  think  is  not  to  be  recommended, 
and  I  never  practise  it  in  this  situation,  as  it  is  more  diffi- 
cult to  keep  this  part  at  rest. 

Hypodermic  Injections. — The  syringe  used  to  make 
hypodermic  injections  is  provided  with  a  perforated 
needle,  which  is  passed  into  the  cellular  tissue  (Fig.  150). 
Care  should  be  taken  to  see  that  the  instrument  and  needle 
are  perfectly  clean  before  being  used ;  they  should  be 
rendered  aseptic  by  soaking  them  for  a  few  minutes  in 
boiling  water  or  in  a  5  per  cent,  carbolic  solution.  Hypo- 
dermic injections  are  generally  made  into  parts  in  which 


INJECTION  OF  ANTITOXINS.  215 

the  cellular  tissue  is  abundant,  and  great  care  should  he 
observed  to  avoid  introducing  the  needle  into  a  large  vein 
or  artery,  as  by  neglect  of  this  precaution  serious  symp- 
toms have  resulted,  from  the  drug  being  thrown  rapidly 
into  the  circulation  instead  of  being  slowly  absorbed  from 
the  subcutaneous  cellular  tissue ;  injury  of  superficial 
nerves  should  also  be  avoided.  Care  should  also  be  taken 
to  see  that  the  solutions  employed  are  sterilized  if  possi- 
ble, and  freshly  made  solutions  should  be  preferred. 

To  avoid  using  solutions  for  hypodermic  use  which 
undergo  change  in  keeping,  it  will  be  found  convenient 
to  use  the  compressed  pellets  which  are  prepared  by  manu- 
facturing chemists,  the  alkaloids  being  compressed  with  a 
little  sulphate  of  sodium,  which  increases  their  solubility, 

Fig.  150. 


Hypodermic  syringe  and  needles. 

the  solution  being  prepared  with  boiled  water  just  before 
being  used. 

The  portions  of  the  body  usually  selected  for  hypo- 
dermic injection  are  the  outer  surface  of  the  thighs  or 
arms  and  the  anterior  surface  of  the  forearms.  In  making 
a  hypodermic  injection,  the  syringe  is  charged  and  the 
needle  is  fastened  to  the  nozzle  of  the  syringe ;  the  skin 
is  next  pinched  up  and  the  needle  is  quickly  thrust 
through  this  into  the  cellular  tissue  (Fig.  151) ;  the  syringe 
is  then  emptied  by  pressing  down  the  piston,  and  when 
the  cylinder  is  empty  the  needle  is  withdrawn. 

Injection  of  Antitoxins. — In  the  treatment  of  diseases 
such  as  diphtheria  and  tetanus  by  the  injection  of  serum, 
the  hypodermic  method  is  made  use  of;  in  using  anti- 
toxin injections  in  diphtheria  the  dose  of  the  antitoxin  is 
proportionate  to  the  age  and  weight  of  the  patient  as  well 


216 


MINOR  SURGERY. 


as  to  the  severity  and  duration  of  the  disease.  A  child 
three  years  old  should  be  given  1000  units;  an  adult, 
not  less  than  1500  units,  and  the  injection  should  be 
repeated  in  twelve  to  twenty-four  hours.  Before  em- 
ploying the  injection  the  skin  should  be  sterilized,  and 


Fig.  151. 


Method  of  giving  a  hypodermic  injection. 

the  best  variety  of  syringe  to  employ  is  one  holding  about 
20  c.c.  (Fig.  152). 

It  is  well  to  have  the  needle  connected  with  the  syringe 
by  a  short  rubber  tube,  so  that  the  needle  will  not  be 
broken  if  the  patient  struggles.  The  injections  are 
usually   made  below  the  angle  of  the  scapula  or  in  the 

Fig.  152. 


H.    K.    MULFORD    CO.,    PHILADA 


Syringe  for  serum-injection. 

lumbar  region,   and   the   serum   is   introduced   slowly   to 
avoid  local  reaction. 

Injections  of  Mercury  in  Syphilis. — Injections  of  mer- 
cury may  be  made  into  the  subcutaneous  tissue  of  the 
loins,  buttocks,  or  scapular  regions  in  the  treatment  of 
syphilis.  Injections  may  also  be  into  the  veins.  The 
solution  most  commonly  used  is  a  1  per  cent,  solution  of 


EXPLORING-NEEDLE.  217 

the  cyanide  of  mercury,  20  minims  being  injected  every 
day  or  on  alternate  days. 

Exploring-needle.— This  consists  of  a  fine-grooved 
needle  fitted  into  a  handle  (Fig.  153),  which  is  introduced 
into  tumors  or  swellings  to  ascertain  the  nature  of  their 
contents,  and  its  use  is  often  of  service  for  purposes  of 

Fig.  153. 


Exploring-needle. 


diagnosis.  The  exploring-trocar  (Fig.  154)  is  employed 
for  the  same  purpose,  or  the  needle  of  the  hypodermic 
syringe  or  a  fine  needle  attached  to  an  aspirator  may  be 
used  for  a  like  purpose.  When  either  the  exploring-needle 
or  trocar  is  employed,  care  should  be  taken  to  see  that  it 
is  rendered  perfectly  aseptic  before  being  used  ;  otherwise 
its  employment  is  not  without  danger,  for  we  have  seen 
the  introduction  of  an  exploring-needle  into  an  effusion 
in  a  joint  for  diagnostic  purposes  followed  by  infection 


Fig.  154. 


Exploring-trocar. 

and  destruction  of  the  joint,  which  subsequently  necessi- 
tated its  excision. 

Skin-grafting. — This  is  a  surgical  procedure  which 
may  be  employed  to  fill  a  gap  in  the  tissues  or  to  hasten 
cicatrization  where  large  granulating  surfaces  are  exposed, 
such  as  result  from  extensive  operations  and  from  burns. 

The  operation  consists  in  applying  shavings  of  the  epi- 
dermis, or  of  the  epidermis  and  cutis  together,  to  the 
granulating  surface  and  holding  them  in  contact  with  it 
for  a  few  days ;  the  grafts  often  seem  to  disappear,  but  at 


218  MINOR  SURGERY. 

the  end  of  a  few  days,  if  the  part  is  closely  inspected, 
bluish-white  points  will  be  seen  to  occupy  the  positions  at 
which  the  grafts  were  applied,  which  become  converted 
into  isolated  cicatrices  from  which  the  healing  process 
rapidly  extends.  To  have  a  successful  result  follow  the 
use  of  skin-grafts,  the  surface  of  the  ulcer  should  be 
healthy,  and  its  surface  as  well  as  the  surrounding  skin 
rendered  aseptic,  and  the  grafts  should  be  applied  at  a 
number  of  points. 

The  surface  from  which  the  grafts  are  to  be  taken 
should  also  be  rendered  aseptic,  and  the  skin  should  be 
removed  by  scissors  or  by  a  sharp  razor,  or  by  raising 
the  epidermis  with  a  needle  or  with  forceps,  and  cutting 
out  a  small  portion  with  a  sharp  scalpel.  The  graft  is 
next  applied  to  the  granulating  surface  with  its  raw  sur- 
face in  contact  with  the  granulations ;  after  a  sufficient 
number  of  grafts  have  been  applied,  a  piece  of  sterilized 
protective  is  laid  over  them  and  is  held  in  place  by  means 
of  a  few  strips  of  isinglass  plaster.  A  sterilized  gauze 
dressing  is  next  applied,  and  the  dressing  is  not  disturbed 
for  a  week  or  ten  days,  at  which  time,  if  the  grafts  have 
taken,  isolated  cicatrices  at  the  points  where  the  grafts 
were  applied  will  be  found. 

Thiersch's  Method. — In  skin-grafting  according  to  this 
method,  the  surface  of  the  ulcer  is  rendered  aseptic,  and 
all  antiseptics  are  washed  away  with  sterilized  salt  solu- 
tion. The  surface  of  the  ulcer  is  next  curetted  to  remove 
soft  granulations,  and  it  is  then  irrigated  and  covered 
with  protective,  and  a  compress  applied  to  control  bleed- 
ing. Shavings  of  skin  are  then  removed  from  a  surface — 
which  has  been  rendered  aseptic — by  means  of  a  razor  or 
section  knife  ;  the  use  of  McBurney's  hooks  will  facilitate 
the  removal  of  the  grafts.  Each  graft  should  be  as  long 
and  broad  as  possible,  and,  when  cut,  it  should  be  floated 
from  the  section  knife  upon  the  prepared  surface  of  the 
ulcer  by  a  stream  of  salt  solution  and  gently  pressed  into 
place.  After  a  sufficient  number  of  grafts  have  been  ap- 
plied, strips  of  protective  are  laid  over  the  surface  of  the 
grafts,  and  over  these  is  placed  a  compress  moistened  with 


BONE-GRA  FTING.  219 

salt  solution  and  covered  by  protective,  and  a  few  la  vers 
of  sterilized  gauze  and  cotton  are  next  applied  over  this, 
and  the  dressing  is  held  in  position  by  a  bandage. 

The  dressings  need  not  be  removed  for  a  week  or  ten 
days,  and  a  second  dressing  should  be  applied  in  the  same 
manner  until  the  grafts  have  become  thoroughly  vitalized. 
The  skin  of  the  bellies  or  backs  of  frogs,  or  the  hairless 
skin  of  young  animals  may  be  used  in  place  of  human 
skin. 

Krause's  Method. — Skin-grafting  is  sometimes  accom- 
plished by  immediately  applying  an  isolated  piece  of  skin 
to  a  raw  surface  to  fill  a  gap;  the  graft  in  such  cases 
includes  the  whole  thickness  of  the  skin,  but  has  all  of 
the  cellular  tissue  removed  from  it,  and  should  be  cut 
one-third  larger  than  the  gap  to  be  filled,  to  allow  for  the 
shrinking  after  its  removal,  and  is  secured  in  position  by 
sutures. 

Bone-grafting. — This  procedure  is  resorted  to  to 
replace  portions  of  bone  which  have  been  separated,  to 
fill  up  cavities  in  bone,  or  to  restore  the  continuity  of  the 
long  bones.  The  bone  to  be  introduced  should  be  ren- 
dered thoroughly  aseptic,  and  should  be  placed  in  a  steril- 
ized salt  solution  at  a  temperature  of  100°  to  105°  F.;  it 
maybe  inserted  in  one  piece  or  broken  into  fragments  and 
laid  over  the  surface. 

AA  hen  it  is  desired  to  restore  the  continuity  of  one  of 
the  long  bones,  after  the  surfaces  of  the  bone  have  been 
exposed  and  rendered  aseptic  a  bone  is  removed  from  a 
freshly  killed  animal,  is  rendered  aseptic,  and  fitted  into 
the  gap  and  secured  to  the  ends  of  the  bone  by  sutures. 
Or  a  portion  of  the  bone  may  be  partially  separated  by  a 
chisel  and  fitted  into  the  gap,  or  is  split  into  strips  and 
packed  into  the  cavity. 

In  the  case  of  parallel  bones,  such  as  the  tibia  and  fibula, 
where  there  has  been  a  loss  in  substance  of  the  tibia,  the 
fibula  has  been  divided  on  a  line  with  the  lower  end  of  the 
tibia,  and  after  freshening  the  end  of  the  tibia  the  upper 
end  of  the  lower  fragment  of  the  fibula  is  shifted  over  to 
the  tibia  and  secured  to  it  by  sutures. 


220  MINOR  SURGERY. 

Bone-grafting  may  also  be  very  satisfactorily  accom- 
plished by  means  of  Senn's  decalcified  bone  plates  or  chips, 
which  will  be  found  useful  in  filling  up  the  cavities  result- 
ing from  extensive  removals  of  bone  in  the  operations 
for  necrosis  or  caries. 

In  such  cases,  after  the  cavity  has  been  sterilized,  it  is 
dusted  with  iodoform  and  is  then  packed  with  bone  chips ; 
iodoform  is  next  dusted  over  them  and  they  are  covered 
by  a  piece  of  protective.  A  compress  of  iodoform  or 
sterilized  gauze  and  bichloride  cotton  is  next  applied,  and 
the  dressing  is  held  in  position  by  a  bandage. 

When  bone  plates  are  employed,  they  are  cut  to  fit  the 
cavity,  and  provision  should  be  made  for  drainage. 

Preparation  of  Decalcified  Bone  Chips  or  Plates. — Take 
sections  of  the  compact  tissue  of  the  fresh  tibia  or  femur 
of  an  ox,  several  inches  in  length,  remove  the  periosteum 
and  medullary  tissue,  split  in  pieces  one-half  an  inch  in 
width,  and  place  them  in  a  15  per  cent,  watery  solution 
of  hydrochloric  acid,  allowing  them  to  remain  in  this  for 
three  weeks,  changing  the  solution  daily.  At  the  end  of 
this  time  they  should  be  removed,  thoroughly  washed,  and 
cut  in  thin  strips  or  plates.  They  should  then  be  washed 
in  a  weak  solution  of  caustic  potash,  and  placed  for  forty- 
eight  hours  in  a  1  :  1000  bichloride  solution.  After  this 
they  may  be  kept  in  a  solution  of  iodoform  in  ether,  or  in 
a  1  :  500  solution  of  bichloride  in  alcohol  until  required 
for  use ;  before  being  used  they  should  be  soaked  in  a 
1  :  2000  bichloride  solution. 

Muscle-grafting  and  nerve-grafting  are  also  occasionally 
resorted  to  to  supply  deficiencies  in  muscles  or  nerves, 
fresh  muscle  or  nerve  tissue  being  employed  to  fill  up  the 
gap. 

Electrolysis. — Electrolysis,  or  the  chemical  decomposi- 
tion induced  by  electricity,  is  employed  in  surgery  to  de- 
stroy morbid  products,  tumors,  or  exudations.  For  this 
procedure,  a  galvanic  or  continuous-current  battery  is  re- 
quired, which  is  provided  with  electrodes  and  needles  of 
suitable  shapes.  In  applying  electrolysis  to  a  tumor,  for 
instance,  the  needle  connected  with  one  of  the  poles  of  the 


GA  L  VA  NO-CA  UTER  Y. 


221 


battery  is  inserted  into  the  tumor,  and  the  other  rheophore 
is  applied  to  the  surface  of  the  body,  or  two  fine  needles, 
carefully  insulated  nearly  to  their  extremities,  are  con- 
nected with  both  poles  of  the  battery  by  conducting  cords; 
these  are  introduced  into  the  tumor  and  a  weak  current  is 
allowed  to  pass.  The  strength  of  the  current  is  gradually 
increased  as  the  operation  advances ;  the  current  is  passed 
for  fifteen  or  twenty  minutes,  and  the  procedure  is  repeated 
at  intervals  of  several  days  until  some  decided  change 
occurs  in  the  tumor. 

Electrolysis  has  been  applied  with  success  in  the  treat- 
ment of  aneurism  inaccessible  to  other  operative  proced- 
ures, in  malignant  growths,  in  nsevi,  goitres,  cysts,  and 
hydatids.  It  is  at  the  present  time  the  most  satisfactory 
method  of  removing  superfluous  hairs  from  those  portions 
of  the  body  in  which  their  presence  causes  disfigurement. 

Galvano-cautery. — Gralvano-cautery  batteries  are  con- 
structed with  plates  of  large  size,  placed  closely  together, 

Fig.  155. 


Electrodes  for  galvano-cautery. 


so  that  the  internal  resistance  is  reduced  and  a  current  is 
quickly  obtained  which  will  keep  a  metallic  electrode  at  a 
white  heat.  The  advantage  in  the  use  of  this  form  of 
cautery  is  that  the  electrode  can  be  introduced  into  the 
cavities  of  the  body  while  cold  and  quickly  heated  to 
the  desired  temperature.  The  electrodes  are  made  of 
various  shapes  and  sizes,  according  to  the  object  desired 
(Fig.  155).  The  galvano-cautery  is  applied  for  the  same 
purpose  as  the  actual  cautery ;  but,  as  previously  stated, 
its  use  is  more  convenient  in  the  cavities  of  the  body, 
its  action  can   be  more  easily  localized,  and   by  its   use 


222  MINOR  SURGERY. 

hemorrhage  is  avoided.  It  is  frequently  employed  to 
destroy  morbid  growths  in  the  nasal  passages,  the  throat, 
vagina,  or  uterus,  and  also  may  be  employed  in  the  treat- 
ment of  superficial  external  growths ;  in  using  it  for  the 
removal  of  growths  from  the  mucous  membrane,  its  appli- 
cation may  be  rendered  practically  painless  by  previously 
thoroughly  cocainizing  the  parts. 

Faradization. — The  application  of  electricity  in  this 
form  is  often  employed  in  surgical  affections ;  in  cases  of 
wasting  of  the  muscles  following  fractures  or  sprains,  in 
some  forms  of  club-foot,  and  in  lateral  curvature  of  the 
spine  the  judicious  use  of  the  faradic  current  will  often  be 
found  to  be  followed  by  the  most  satisfactory  results.  The 
current  is  applied  in  such  a  manner  as  to  bring  about 
contraction  of  the  affected  or  wasted  muscles,  and  thus 
improve  their  nutrition. 

Franklinization. — The  earliest  application  of  electricity 
in  the  treatment  of  disease  was  in  the  form  of  statical 
electricity,  and  although  it  fell  into  disuse,  it  has  recently, 
with  the  perfection  of  modern  machines,  been  widely  re- 
vived. In  applying  statical  electricity  the  patient  may 
be  treated  by  insulation,  or  the  so-called  dry  electric  bath. 
The  second  method  of  using  statical  electricity  is  by  sparks 
or  shocks  from  a  Leyden  jar,  which  is  charged  from  the 
prime  conductor  of  an  electrical  machine  in  motion,  or  by 
the  electric  brush.  McClure  states  that  in  the  static 
induced  current  we  have  a  means  of  producing  muscular 
contractions  when  failure  results  from  the  strongest  faradic 
currents  that  can  be  borne  by  the  patient. 

The  CystOSCOpe. — This  is  an  instrument  employed  for 
ocular  examination  of  the  walls  of  the  bladder,  and  is  one 
of  the  most  important  and  useful  of  the  electric-lamp 
instruments.  A  cystoscope  consists  of  a  beaked  sound  in 
which  there  is  a  telescopic  arrangement,  by  which  the  inner 
surface  of  the  bladder  is  viewed  through  a  small  window 
of  rock  crystal.  The  lamp  is  enclosed  in  the  beak  of  the 
instrument  and  throws  its  light  through  another  window, 
also  of  crystal,  upon  any  part  of  the  bladder  wall.  The 
bladder  should  contain  six  or  eight  ounces  of  clear  urine 


THE   URETHROSCOPE. 


223 


or  dear  water  if  a  proper  view  of  the  walls  is  to  be  ob- 
tained. If  the  fluid  is  turbid  or  contains  blood,  the  view 
is  very  much  obscured;  if  too  little  fluid  be  present  in  the 
bladder,  the  beak  of  the  instrument  containing  the  lamp 
is  likelv  to  become  buried  in  the  folds  of  mucous  mem- 
brane and  the  light  will  be  cut  off,  and  the  mucous  mem- 
brane may  be  burned.  The  bladder  may  be  emptied  of 
urine  and' distended  with  air  which  accomplishes  the  same 
purpose.  A  certain  amount  of  practice  is  required  to  use 
the  cystoscope  properly  and  to  recognize  the  appearance 

Fig.  156. 


Illumination  of  the  wall  of  bladder  by  cystoscope.    (Park.) 

of  the  mucous  membrane  of  the  bladder  in  health  and  in 
its  varied  morbid  conditions. 

The  Urethroscope. — The  urethroscope  consists  of  a 
straight  metal  tube  provided  with  an  obturator  of  hard 
rubber,  which  projects  slightly  beyond  the  end  of  the  tube. 
This  tube  is  introduced  into  the  urethra  until  the  bladder 
is  reached,  when  it  is  slightly  withdrawn  and  the  obturator 
removed.  The  instrument  is  then  attached  to  the  mirror 
of  an  electric  lamp,  by  which  a  strong  light  is  thrown  into 
the  tube,  and  as  the  tube  is  withdrawn  the  urethra  is  ex- 


224 


MINOR  SURGERY. 


posed  to  view.     By  means   of  the    urethroscope  a  very 

accurate  inspection  of  all  portions  of  the  urethra  can  be 

obtained. 

Fig.  157. 


The  urethroscope. 

The  Panelectroscope. — This  instrument,  introduced 
by  Leiter,  consists  of  an  electric  lantern,  with  tubes  and  a 
mirror.  The  light  from  a  small  incandescent  lamp  is 
projected  by  the  mirror  along  the  tube,  which  is  inserted 
into  the  part  to  be  examined.  Tubes  of  various  sizes  are 
adapted  to  the  instrument.  It  is  employed  for" endoscopy 
of  the  urethra,  ear,  pharynx,  and  stomach. 


MASSAGE. 

Massage  consists  in  a  variety  of  manipulations,  such 
as  pinching  up  the  integument  and  muscles,  and  rolling 
them  between  the  thumb  and  fingers ;  in  stroking  or  rub- 
bing the  surface  with  the  palm  of  the  hand  from  the 
periphery  toward  the  centre,  to  empty  the  distended  veins 
and  lymphatics  ;  rubbing  the  parts  circularly  with  the 
extremities  of  the  fingers  and  thumbs  or  the  palms  of 
the  hands.  Kneading  of  the  parts  is  another  method  of 
practising  massage.  Massage  may  also  be  practised  by 
tapping  the  surface  of  the  affected  part  more  or  less  forci- 


COMPRESSION.  225 

l>lv  with  the  tips  of  the  fingers  held  in  a  row,  or  with 
the  ulnar  border  of  the  hand  or  the  palm  of  the  hand. 
Before  applying  massage  to  an  affected  part,  if  there  be  a 
heavy  growth  of  hair,  it  should  be  shaved  off;  otherwise 
the  manipulation  may  give  the  patient  pain,  and  irritation  of 
the  hair-follicles  resulting  in  abscesses  will  be  apt  to  occur. 
The  part  should  also  be  rubbed  over  with  olive  oil,  vase- 
line, or  cacao-butter  before  and  during  the  manipulations. 

Massage  is  employed  often  with  advantage  in  the  treat- 
ment of  Sprains  and  strains  in  their  subacute  and  chronic 
stages.  Lucas-Championniere  advocates  and  practises 
immediate  and  continuous  massage  in  the  treatment  of 
fractures.  It  will  also  be  found  of  great  service  in  the 
later  treatment  of  fractures  involving  the  joints  or  their 
vicinity,  in  restoring  the  motion  of  the  parts  as  well  as  in 
improving  the  nutrition  of  muscles  which  have  become 
wasted  from  disuse. 

Passive  Motion. — This  manipulation  consists  in  alter- 
nated flexing  and  extending  or  rotating  the  limb,  to  imi- 
tate the  normal  joint-movements.     The  motions  should  be 
carefullv  practised,  and  in  cases  of  fracture  they  should  not 
be  undertaken,  as  a  rule,  until  there  is  firm  union  at  the 
seat  of  fracture  ;  if  for  any  reason  passive  motion  is  made 
use  of  before  this  time,  the  fragments  should  be  firmly 
supported  while  it  is  being  employed.     Other  forms  of 
massage,  such  as  stroking  and  kneading,  may  be  employed 
in  conjunction  with  passive  motion  in  the  treatment  of  the 
stiffness  of  joints  resulting  from   fractures,  dislocations, 
and  sprains ;  passive  motion  applied  in  this  manner  will 
often  restore  the  function  of  a  stiff  joint  more  satisfactorily 
and  with  less  pain  to  the  patient  than  the  forcible  manipu- 
lations which  are  sometimes  practised  under  an  anaesthetic. 
Compression. — This    is   a  valuable   means  of  dimin- 
ishing swelling  in  the  early  stages  of  inflammation,  and 
of  bringing  about  absorption  of  the  effusion  in  the  later 
stages.     It"  may    be    applied    by    means    of    compresses, 
bandages,  or  strapping.     Pressure  applied   in  this  manner 
is  often   emploved   in   the   treatment   of   injuries  of   the 
joints  and  bursa?,  and  in   chronic  inflammatory  swellings. 

15 


226 


MINOR  S URGER  Y. 


It  should  be  used  witli  caution  when  the  circulation  in 
the  tissues  is  impaired. 

Application  of  Hot  Air. — The  employment  of  a  con- 
tinuous hot-air  bath  has  recently  been  advocated  in  the 
treatment  of  painful  and  partially  anchylosed  joints, 
synovitis,  teno-synovitis,  and  chronic  rheumatism.  In 
applying  this  method  of  treatment,  the  limb  is  wrapped 
loosely  in  lint  and  introduced  into  a  metallic  cylinder 
(Fig.  158),  the  temperature  of  which  is  raised  to  about 

Fig.  158. 


Apparatus  for  hot-air  treatment. 

300°  F.  The  part  is  exposed  to  this  temperature  for 
three-quarters  of  an  hour  to  one  hour,  and  at  intervals 
of  twenty  minutes  the  door  is  opened  for  a  short  time  to 
allow  the  ingress  of  fresh  air;  if  the  part  is  perspiring, 
it  is  wiped  dry,  for  if  moisture  is  present  upon  the  limb 
burns    are    likely  to  result.     Under  this  form  of  treat- 


THE  ( 'L  INK I  I L   THERMOMETER.  227 

ment  pain  is  often  temporarily  or  permanently  relieved, 
synovial  effusions  absorbed,  and  adhesions  are  softened 
and  disappear.  Clinically  it  has  been  found  that  the  best 
results  following  this  method  of  treatment  have  occurred 
in  painful  and  anchylosed  joints  following  traumatisms; 
and  although  temporary  improvement  has  occurred  in 
rheumatic,  gouty,  tuberculous,  and  gonorrheal  affections 
of  joints,  permanent  improvement  is  not  so  likely  to 
result. 

The  Clinical  Thermometer. — For  clinical  observa- 
tions two  thermometer  scales  are  in  general  use,  the  centi- 
grade and  the  Fahrenheit;  the  latter  is  the  one  commonly 
employed  in  America  and  in  England.  This  scale  has  a 
limited  range  above  and  below  the  normal  bodily  tem- 
perature,'  which  is  98.4°  Fahrenheit  or  36°  centigrade. 
Thermometers  are  now  made  with  a  convex  surface,  which 

Fig.  159. 


T- ■ i r 


.,....,,... |....|. 


Mao       9  0 5 100 5_- -  110 

Clinical  thermometer. 

serves  to  magnify  the  column  of  mercury,  and  thus 
enables  the  observer  without  difficulty  to  note  the  position 
of  the  index  (Fig.  159). 

The  temperature  of  the  body  may  be  taken  in  the 
mouth,  axilla,  vagina,  or  rectum ;  the  two  former  loca- 
tions are  those  generally  selected.  When  taken  in  the 
axilla,  care  should  be  exercised  to  see  that  no  clothing  is 
interposed  between  the  skin  and  the  instrument ;  and 
when  the  mouth  is  used  for  thermometric  observations  the 
patient  should  be  instructed  to  keep  his  lips  tightly  closed 
and  breathe  through  his  nose.  The  thermometer  should 
be  kept  in  place  for  from  three  to  five  minutes. 

Surface  thermometers  are  sometimes  employed,  the 
instruments  for  this  purpose  having  bulbs  of  a  discoid 
shape  (Fig.  160),  or  being  drawn  out  in  the  form  of  a 
spiral  or  coil.  In  using  this  form  of  thermometer  to  de- 
termine the  amount  of  variation  of  the  surface  tempera- 


3 


228 


MINOR  SURGERY. 


Fig.  160. 


Surface  thermometer 


ture,  the  temperature  of  corresponding  parts  of  the  body 
on  the  opposite  side  and  the  general  temperature  of  the 
body  should  be  taken  at  the  same  time. 


SKIAGRAPHY,  OR  EMPLOYMENT   OF   THE  RONTGEN 

RAYS. 

Rontgen,  in  1895,  while  investigating  the  cathode  rays 
as  developed  in   Crookes's  tubes,  discovered  the  energy 

Fig.  161. 


Apparatus  for  taking  skiagraphs.    (Paek.) 

which  he  named  a-rays.  The  rays  are  invisible,  but  have 
great  power  of  penetration,  and  pass  through  many  sub- 
stances which  are  opaque  to  sunlight  and  ordinary  electric 
lia;ht.  If  the  rays  are  intercepted  by  a  body  not  readily 
permeable,  which  is  placed  between  the  Crookes's  tube  and 


SKIAGRAPHY.  229 

a  dry  photographic  plate,  a  shadow  will  be  formed,  and  an 
impression  of  this  shadow  will  be  funned  upon  the  plate. 
Such  a  shadow  is  known  as  a  skiagraph.  The  fluoroscope 
consists  of  a  fluorescent  screen,  which  is  so  placed  that 
the  rays  emanating  from  the  Crookes's  tube  and  passing 

Fig,  162. 


Skiagraph  of  fracture  of  both  bones  of  the  forearm. 

through  any  intercepted  substance  to  be  studied  are  re- 
fleeted  directly  upon  it.  If  the  body  is  more  or  less  re- 
sistant, the  observer  can  see  it  clearly  through  the  skin 
and  subcutaneous  tissue. 

The  time  of  exposure  to  the  rays  varies  with  the  strength 


230  MINOR  SURGERY. 

of  the  current  and  the  thickness  of  the  tissues.  The  ex- 
posure is  usually  from  three  to  fifteen  minutes.  The  tube 
should  not  be  placed  too  near  the  surface  of  the  body,  and 
the  exposures  should  be  as  short  as  possible. 

Fig.  163. 


Skiagraph  of  bullet  in  knee-joint.    (Willard.) 

There  occasionally  develops  after  the  use  of  the  #-rays 
a  peculiar  disturbance  of  the  tissues,  probably  trophic  in 
nature,  which  is  known  as  an  .T-ray  burn.  The  skin, 
several  weeks  after  exposure  to  the  rays,  may  become 
ulcerated,  the  nails  may  be  lost,  and  a  very  intractable 
form  of  ulceration  or  gangrene  develop. 


SKIAGRAPHY. 


231 


The  awraysare  of  great  value  in  locating  foreign  bodies, 
such  as  needles,  pins,  bullets,  and  pieces  of  glass.  They 
are  employed  also  with  advantage  in  locating  mineral  cal- 
culi  in   the   Madder,  ureter,  and    kidney.     They  are  also 


Fig.  164 


Skiagraph  of  fracture  of  tibia  and  fibula. 

useful  in  detecting  the  presence  of  fractures  and  disloca- 
tions. In  fractures  about  the  joints,  epiphyseal  separa- 
tions, and  ununited  fractures,  their  use  has  proved  most 
satisfactory.  Skiagraphs  of  a  fracture  are  shown  in  Figs. 
162  and  164,  of  a  bullet  in  the  knee-joint   in  Fig.  163, 


232 


MINOR  SURGERY. 

Fig.  1G5. 


Skiagraph  of  separation  of  upper  epiphysis  of  the  humerus. 

and  of  an  epiphyseal  separation  of  the  humerus  in  Fig. 
165. 


ANESTHETICS. 

Anaesthesia  may  be  local,  regional,  or  general. 

Local  Anaesthesia. — This  results  from  the  direct  appli- 
cation of  anaesthetic  agents  to  nerve-terminations,  and 
causes  analgesia  of  the  tissues  to  a  limited  extent  only. 
It  may  be  produced  by  the  use  of  cold,  a  spray  of  ether, 
rhigolene,  ethyl  chloride,  cocaine  or  eucaine  hydrochlo- 
rate,  holocaine  hydrochlorate,  guaiacol,  or  by  Schleich's 
method  of  infiltration. 

Regional  Anaesthesia, — This  is  also  sometimes  described 


ANAESTHETICS. 


233 


as  neural  anaesthesia,  and  results  from  the  application  of 
anaesthetic  agents  to  the  nerve-rootSj  nerve-trunks,  or  the 

spinal  curd.  The  analgesia  in  this  form  of  anaesthesia 
extends  from  the  point  of  application  to  the  tissues  sup- 
plied by  the  nerve  or  nerves,  and  therefore  is  not  limited 

in  extent. 

General  Anaesthesia.— This  is  characterized  by  un- 
consciousness, as  well  as  abolition  of  sensation,  and  may 
be  induced  by  the  administration  of  nitron-  oxide  gas, 
ether,  chloroform,  bromide  of  ethyl,  A.-C.-E.  mixture  or 
Schleich's  anaesthetic  mixture.  It  may  also  be  induced  by 
a  combination  of  these  substances  with  nitrous  oxide  gas 
or  oxygen.  Hypnotism  may  also  be  employed  to  produce 
general  anaesthesia. 

Local  Anaesthesia. 

Cold. — Local  anaesthesia  may  be  produced  by  the  appli- 
cation of  cold,  either  by  a  piece  of  ice  or  a  mixture  of  ice 


Fig.  166. 


Application  of  rhigolene  spray. 

and  salt  held  in  contact  with  the  part  for  one  or  two  min- 
ute-, or  by  directing  a  spray  of  rhigolene  or  sulphuric  ether 
upon  the  surface  of  the  part  whose  sensibility  is  to  be 
obtunded  (Fig;.  166). 

Chloride  of  Ethyl.— This  substance  is  used  also  to 
produce  local  anaesthesia,  and  is  conveniently  furnished 
in  glass  tubes,  one  end  of  which  is  drawn  out  into  a  line 


234  MINOR  SURGERY. 

point  and  hermetically  sealed.  When  used,  the  end  of  the 
tube  is  broken  off  and  a  fine  jet  of  ethyl  is  projected  upon 
the  part  to  be  anaesthetized,  the  warmth  of  the  hand  being 
sufficient  to  force  the  fluid  from  the  tube.  This  form  of 
local  anaesthesia  is  made  use  of  in  minor  surgical  pro- 
cedures, such  as  aspiration,  the  opening  of  abscesses,  and 
the  removal  of  superficial  tumors. 

Rapid  Respiration. — Rapidly  repeated  deep  inspira- 
tions kept  up  for  a  few  minutes  will  produce  insensibility 
to  pain,  but  sensibility  to  contact  is  not  obliterated.  This 
form  of  anaesthesia  may  be  made  use  of  in  slight  opera- 
tions, such  as  opening  an  abscess. 

Cocaine. — Local  anaesthesia  produced  by  the  employ- 
ment of  an  aqueous  solution  of  the  hydrochlorate  of 
cocaine,  in  strength  from  1  to  2  per  cent.,  is  often  made 
use  of  in  minor  surgical  procedures.  Solutions  as  strong 
as  10  or  12  per  cent,  were  formerly  employed,  but  experi- 
ence has  proved  that  there  is  always  danger  in  the  use 
of  the  stronger  solutions  of  cocaine,  so  that  it  is  now  con- 
sidered wise  not  to  use  one  stronger  than  1  or  2  per  cent., 
as  the  full  analgesic  effect  can  be  obtained  by  a  solution 
of  this  strength.  When  mucous  membrane  is  to  be  oper- 
ated upon  or  growths  removed  from  it,  analgesia  is  pro- 
duced by  brushing:  over  the  surface  with  the  solution  of 
cocaine,  or  by  applying  to  the  part  for  a  few  minutes  a 
compress  of  absorbent  cotton  saturated  with  it;  in  mucous 
cavities  the  latter  method  of  application  will  be  found 
most  convenient.  In  using  a  solution  of  cocaine  to  pro- 
duce anaesthesia  in  operations  upon  the  eye,  a  2  per  cent, 
solution  is  dropped  into  the  eye,  and  is  repeated  until 
analgesia  is  complete. 

In  applying  cocaine  to  the  urethra,  a  1  to  2  per  cent, 
solution  is  injected,  and  is  allowed  to  remain  for  two  or 
three  minutes;  more  than  1  or  2  grains  should  not  be 
injected  at  one  time,  as  fatal  results  have  followed  the 
injection  of  larger  quantities ;  this  is  especially  the  case 
in  using  cocaine  in  the  urethra  and  the  rectum,  and  in 
these  situations  great  caution  should  be  exercised  in  its 
employment. 


ANESTHETICS.  235 

When  it  is  desired  to  produce  local  anaesthesia  of  the 
skin  or  deeper  tissues,  the  application  of  cocaine  to  the 
surface  is  not  satisfactory,  and  it  should  in  such  cases  be 
injected  hypodermically  into  the  deeper  layers  of  the  skin 
and  into  the  cellular  tissue  of  the  parts  to  be  operated 
upon  ;  to  avoid  multiple  punctures,  the  needle  is  not  com- 
pletely withdrawn  from  the  wound,  but  its  direction  is 
changed  and  the  solution  is  thrown  into  different  portions 
of  the  tissues.  It  is  well,  in  situations  where  it  can  be 
accomplished,  to  cut  off  the  circulation  from  the  part  to 
be  operated  upon  by  placing  around  it  a  rubber  strap  or 
tube,  which  prevents  rapid  absorption  of  the  cocaine  into 
the  general  blood-current. 

Corning  recommends  injection  of  cocaine  by  the  gal- 
vanic current.  The  skin  of  the  region  to  be  anaesthetized 
is  perforated  by  a  number  of  fine  needles,  and  the  perfor- 
ated area  is  covered  with  several  thicknesses  of  flannel 
cloth  saturated  with  a  5  per  cent,  solution  of  cocaine.  A 
layer  of  potters'  clay  of  the  consistence  of  bread-dough, 
containing  a  thin  sheet  of  copper,  is  placed  upon  the 
flannel,  and  the  copper  plate  connected  by  an  insulated 
wire  with  the  positive  pole  of  a  galvanic  battery.  The 
negative  pole  should  consist  of  a  broad,  flat  sponge  wrung 
out  in  hot  water  and  held  as  near  as  possible  to  the  posi- 
tive pole  without  touching  it.  The  more  extensive  the 
surface  to  be  anaesthetized  the  stronger  should  be  the  cur- 
rent. From  three  to  six  cells  may  be  used,  and  the  time 
required  is  from  ten  to  twenty  minutes. 

Some  persons  have  an  idiosyncrasy  for  cocaine,  and 
children  seem  more  susceptible  to  its  constitutional  effects 
than  adults.  I  have  seen  several  instances  in  children  in 
which  marked  symptoms  of  cocaine  poisoning  resulted 
from  the  application  of  a  4  per  cent,  solution  to  the  nasal 
mucous  membrane. 

The  treatment  of  cocaine  poisoning  consists  in  placing 
the  patient  in  the  recumbent  position  and  the  hypodermic 
injection  of  morphine,  strychnine,  or  ether. 

Cocaine  anaesthesia  may  be  employed  with  advantage 
in  minor   surgical  operations,  such  as  amputations  of  the 


236  MINOR  SURGERY. 

fingers,  circumcision,  opening  of  abscesses,  and  removal 
of  superficial  tumors,  but  its  utility  is  most  marked  in 
operations  upon  the  eye  and  upon  the  mucous  membranes 
of  the  nose,  throat,  rectum,  vagina,  and  urethra.  Applied 
for  a  few  minutes  to  the  surface  of  an  ulcer  which  is  to 
be  cauterized,  it  will  render  the  operation  almost  painless. 

Eucaine  Hydrochlorate. — This  drug,  which  possesses 
the  same  properties  as  cocaine,  as  regards  the  production 
of  analgesia,  is  employed  as  a  local  application  to  mucous 
surfaces,  and  hypodermically  in  the  deeper  tissues  to  pro- 
duce local  and  regional  anaesthesia.  It  has  the  advantage 
over  cocaine  that  it  can  be  used  with  safety  in  much  larger 
quantities,  as  it  is  apparently  free  from  toxic  action. 
Kiessel  states  that  2  grammes  have  been  injected  without 
the  production  of  toxic  symptoms.  It  may  be  used  in 
solutions  varying  in  strength  from  2  to  10  per  cent., 
which  may  be  sterilized  by  heating ;  a  2  per  cent,  solution 
is  that  most  usually  employed  hypodermically. 

Holocaine  Hydrochlorate.— This  drug/ used  in  a  1 
per  cent,  solution,  possesses  as  decided  analgesic  action  as 
cocaine ;  it  is  also  strongly  bactericidal  in  its  action.  It 
may  be  used  locally  without  producing  constitutional 
symptoms,  but  cannot  be  used  internally  or  injected  into 
the  tissues,  on  account  of  its  marked  toxic  action. 

Guaiacol. — This  drug  may  be  used  for  its  analgesic 
effect,  and  is  employed  in  a  solution  of  guaiacol,  grains 
xv  ;  alcohol,  3v  ;  or  in  the  form  of  an  ointment  of  guaiacol, 
5  parts,  to  vaseline,  30  parts ;  or  it  may  be  used  hypoder- 
mically in  a  one-tenth  or  one-twentieth  solution  in  olive 
oil.     Its  hypodermic  use  is  not  unattended  with  danger. 

Infiltration  Anaesthesia. — It  has  been  shown  by  Lie- 
breich  that  the  injection  of  simple  water  into  the  tissues 
in  such  a  way  as  to  produce  an  artificial  cedema  induces 
a  transitory  anaesthesia. 

Schleich  found  that  the  combination  of  a  minute  quan- 
tity of  cocaine  and  morphine  with  a  weak  salt  solution, 
when  injected  hypodermically,  produced  a  local  anaesthesia 
of  longer  duration. 

The  anaesthesia  is  produced  by  the  artificial  ischaemia, 


AN&STHETICS.  SM 

by  the  pressure  of  the  injected  fluids  upoD  the  nerves,  and 
by  the  direct  action  of  the  anaesthetic  substances  on  the 
nerves. 

A  solution  of  1  part  of  cocaine  to  1000  parts  of  steril- 
ized water  may  be  used,  or  the  following  solution  may  be 
employed  : 

Cocaine  liydrochlor gr.  iss. 

Morphia?  hydrochlor gr.  £. 

Sodii  chloridi gr.  iij. 

Aquae  dest onJS;?- 

The  injection  should  first  be  made  into  the  substance  of 
the  skin  itself,  and  then  into  the  cellular  tissues  and  deeper 
structures,  as  desired. 

Barker  recommends  the  following  solution  for  obtain- 
ing infiltration  anaesthesia  :  eucaine,  1  part  to  1000  parts 
of  sterilized  water,  with  8  parts  of  chloride  of  sodium. 
He  also  recommends  elastic  constriction  applied  above 
the  part,  as  a  means  of  increasing  the  action  of  the  drug. 
Solutions  with  the  same  freezing-point  as  the  normal  fluids 
of  the  body  should,  if  possible,  be  used,  as  they  are  in- 
different to  the  tissues — that  is,  they  possess  no  osmotic 
action. 

Infiltration  anaesthesia  has  widely  been  employed  in 
minor  surgical  operations,  and  also  may  be  employed  in 
major  operations,  such  as  herniotomy  and  amputations, 
when  for  any  reason  a  general  anaesthesia  is  not  desirable. 
In  children  and  nervous  subjects  it  cannot  be  employed 
with  advantage.  It  also  has  the  disadvantage  of  causing 
swelling  and  oedema  of  the  tissues  at  the  seat  of  operation, 
which  often  interfere  with  the  satisfactory  recognition  of 
the  various  anatomical  structures. 


Eegional  Anaesthesia. 

This  method,  sometimes  described  as  neural  aruzsth 
consists    in    bringing   anaesthetic    drugs    in    contact    with 
nerve-trunks  at  some   distance  from    the  field  of  opera- 
tion, with  the  view  of  causing   analgesia   in   the  tissues 


238  MINOR  SURGERY. 

supplied  by  them.  For  instance,  in  a  proposed  operation 
upon  the  leg,  the  injection  would  be  made  near  or  into 
the  anterior  crural  and  sciatic  nerves.  Cocaine,  eucaine, 
or  Schleich's  solution  may  be  employed  for  the  pur- 
pose. The  nerves  may  be  anaesthetized  by  the  paraneural 
method,  which  consists  in  injecting  the  solution  in  the 
vicinity  of  the  nerve-trunk  as  near  as  possible  to  the 
nerve ;  or  by  the  direct  intraneural  method,  which  con- 
sists in  producing  anaesthesia  of  the  skin  and  cellular 
tissue,  and  then  exposing  the  nerve-trunks  by  dissection 
and  injecting  the  solution  directly  into  them  by  passing 
the  needle  into  their  substance. 

This  method  of  anaesthesia  has  been  employed  with 
success  both  in  minor  and  major  surgical  operations,  such 
as  the  reduction  of  herniae,  amputations,  and  the  removal 
of  tumors,  and  is  especially  applicable  in  operations  upon 
the  extremities. 

Spinal  Subarachnoid  Injection. — As  the  result  of  the 
work  of  Corning,  Bier,  and  Tuffier,  anaesthesia  by  means 
of  spinal  subarachnoid  injection  of  cocaine  or  eucaine  has 
recently  been  employed  with  satisfactory  results.  At  the 
present  time  this  method  of  anaesthesia  is  resorted  to  only 
in  operations  upon  that  portion  of  the  body  below  the 
diaphragm,  and  injections  are  made  into  the  spinal  canal 
in  the  lumbar  region.  Fifteen  to  20  minims  of  a  2  per 
cent,  cocaine  or  eucaine  solution  are  usually  sufficient  to 
produce  satisfactory  anaesthesia.  The  technique  of  the 
operation  is  as  follows :  The  entire  lumbar  and  sacral 
regions  should  carefully  be  sterilized,  and  the  position  of 
the  third  lumbar  interspace — that  is,  the  space  between 
the  third  and  fourth  lumbar  vertebrae — located.  The 
patient  next  sits  astride  of  the  operating-table  and  bends 
forward  in  the  position  of  ventral  flexion,  with  his  elbows 
resting  upon  his  knees,  which  widens  the  space  between 
the  third  and  fourth  lumbar  vertebrae.  A  few  drops  of 
cocaine  or  eucaine  are  next  injected  into  the  skin  over  the 
centre  of  this  space.  A  needle  between  1  and  2  milli- 
metres in  circumference,  and  about  8  centimetres  in  length, 
attached  to  a  syringe,  is  next  inserted  through  the  skin  mid- 


ANAESTHETICS.  239 

way  between  the  spinous  processes,  or  a  puncture  by  a 
tenotome  may  be  made  through  the  skin,  and  the  needle 
inserted  through  this.  The  needle  and  syringe  should  be 
thoroughly  sterilized  by  boiling  before  being  used.  The 
needle  should  be  pushed  forward  and  a  little  to  the  left, 
to  cause  it  to  enter  the  spinal  canal  in  the  median  line, 
and  as  soon  as  resistance  disappears  and  fluid  appears  in 
the  syringe  it  is  evident  that  the  canal  has  been  entered. 
After  a  few  drops  of  fluid  have  escaped,  the  syringe  is 
removed  from  the  needle  and  replaced  by  one  containing 
the  anaesthetic  solution,  and  15  to  20  minims  of  the  solu- 
tion are  injected  into  the  spinal  canal.  The  needle  is  then 
removed  and  the  puncture  sealed  with  a  small  piece  of 
gauze  and  collodion,  and  the  patient  placed  in  the  recum- 
bent posture.  In  a  few  minutes  anaesthesia  is  usually 
sufficiently  advanced  for  the  operation. 

Subarachnoid  spinal  injection  should  not  be  employed 
in  children,  nor  in  nervous  and  excitable  patients,  but 
may  be  employed  in  cases  where  for  any  cause  a  general 
anaesthetic  is  contraindicated. 

This  method  of  anaesthesia  has  been  employed  success- 
fully in  a  great  variety  of  operations,  and  up  to  the 
present  time  few  fatalities  have  been  reported  as  the  re- 
sult of  its  use ;  but  it  should  be  remembered  that  the  pro- 
cedure is  still  on  trial,  and  that  sufficient  time  has  not 
elapsed  to  show  the  ultimate  result  of  the  injections.  A 
more  extended  use  of  the  method  alone  can  prove  that  it 
is  safer  than  the  general  anaesthetics  now  employed.  The 
restriction  in  its  use  to  operations  in  certain  parts  of  the 
body  also  renders  it  difficult  to  estimate  its  comparative 
safety. 

General  Anaesthesia, 

General  anaesthesia  may  be  produced  by  the  adminis- 
tration of  nitrous  oxide  gas,  ether,  chloroform,  A.-C.-E. 
mixture,  Schleich's  mixture,  or  ethyl  bromide. 

Choice  of  Anaesthetic. — In  selecting  an  anaesthetic,  the 
most  important  considerations  are  its  safety  and  its  suita- 
bility to  the  individual  case.     In  point  of  safety,  nitrous 


240  MINOR  SURGERY. 

oxicle  gas  holds  the  first  place ;  but,  unfortunately,  its  use 
is  restricted  to  cases  in  which  only  a  few  minutes*  anaes- 
thesia is  required.  Statistics  show  that  the  mortality  fol- 
lowing the  administration  of  nitrous  oxide  is  about  1  to 
5,250,000;  of  ether,  1  to  16,675;  of  chloroform,  1  to 
3749.  Gardner's  statistics  show  that  in  22,219  chloro- 
form administrations  there  were  14  deaths ;  while  in 
17,067  administrations  of  ether  or  nitrous  oxide  gas  and 
ether,  there  was  1  death.  It  should  be  remembered,  how- 
ever, that  both  ether  and  chloroform  are  employed  in  the 
most  serious  surgical  procedures,  while  nitrous  oxide  gas 
is  used  only  in  trivial  operations,  so  that  many  of  the 
deaths  attributed  to  ether  and  chloroform  may  have  been 
due  to  conditions  resulting  from  the  operations. 

Nitrous  Oxide  Gas. — Nitrous  oxide  causes  anaesthesia 
by  arresting  the  oxygenation  of  the  blood  while  it  is  in 
contact  with  it,  and,  in  addition,  the  gas  produces  anaes- 
thesia by  direct  action  on  the  cerebral  cortex.  Nitrous 
oxide  gas  is  contraindicated  in  alcoholic  subjects,  or  in 
those  having  marked  atheroma  of  the  arteries,  as  apoplexy 
may  occur,  or  in  any  condition  of  obstructed  respiration. 
The  apparatus  best  suited  for  its  administration  consists 
of  a  cylinder  of  metal  in  which  the  gas  is  compressed, 
which  is  attached  to  a  rubber  bag,  which  has  a  mouth- 
piece fastened  to  it ;  this  is  provided  with  a  double  valve, 
which  prevents  the  expired  air  from  passing  back  into 
the  bag.  The  mouthpiece  is  adjusted  over  the  mouth, 
and  after  removing  any  false  teeth  or  foreign  bodies  from 
the  mouth,  the  patient  is  instructed  to  take  deep,  full 
breaths,  and  in  from  one-half  to  one  minute  the  face 
becomes  congested  and  dusky  and  the  breathing  becomes 
stertorous,  indicating  that  the  patient  is  fully  under  the 
influence  of  the  gas.  The  anaesthesia  from  nitrous  oxide 
cannot  be  prolonged  for  more  than  a  few  minutes,  so 
that  it  can  only  be  employed  in  operations  Avhich  take  a 
short  time  for  their  performance,  such  as  the  extraction 
of  teeth  and  the  opening  of  abscesses.  Unfortunately,  it 
cannot  be  used  in  the  reduction  of  fractures  or  disloca- 
tions, as  it  does  not  produce  complete  muscular  relaxation. 


ANJESTHETH  S  241 

In  England  nitrous  oxide  is  frequently  used  to  produce 
anaesthesia,  and  when  this  result  is  accomplished  the  anaes- 
thesia is  kept  up  by  the  administration  of  ether  by  the 
employment  of  a  special  apparatus  devised  for  this  pur- 
pose. '  Nitrous  oxide  gas  is  commonly  employed  in  dental 
surgery  to  produce  anaesthesia  for  the  removal  of  teeth, 
but  is  also  occasionally  employed  in  minor  surgical  opera- 
tions ;  but  from  the 'fart  that  the  apparatus  for  its  ad- 
ministration is  a  bulky  one,  its  use  is  not  so  convenient  as 
ether  or  chloroform,  and  in  this  country  it  is  not  much 
employed  in  general  surgery. 

Nitrous  oxide  gas  may  also  be  administered  by  the  open 
method,  or  by  an  open  'inhaler  resembling  that  of  Allis. 
The  °;as,  being  heavier  than  the  air,  is  introduced  into  the 
inhaler  and  falls  to  the  bottom.      Flux,  who  has  employed 
this  method  of  administration  in  a  number  of  cases,  claims 
that  by  its  employment  excitement,  stertor,  lividity,  strug- 
gling,'and  convulsive  movements  are  done  away  with. 
'  Nitrous  Oxide  Gas  and  Oxygen.— The  administration 
of  nitrous  oxide  gas  with  oxygen  has  been  found  by  Hewitt 
to  diminish  the  asphyxial  symptoms,  so  that  a  more  pro- 
longed and  tranquil  anaesthesia  can  be  safely  obtained.    The 
anaesthetic  state  is  not  produced  as  rapidly  as  by  nitrous 
oxide  gas  alone,  but    it  may  be  prolonged   by  a   skilful 
anaesthetizer  for  an  hour  or  more.     It  is  administered  by 
a  special  apparatus,  by  which  the  administrator  can  increase 
or  diminish  the  amount  of  oxygen,  according  to  the  symp- 
toms presented.    Cyanosis,  stertor,  and  muscular  twitching 
call  for  an  increase  in  the  oxygen,  whereas  symptoms  of 
excitement  call  for  its  diminution.     In  children  and  in 
aged  and  anaemic  subjects  the  amount  of  oxygen  may  be 
increased  rapidly  ;  whereas  in  strong,  full-blooded  subjects 
the  quantitv  of  oxvgen  should  be  increased  cautiously. 

Ether.— Sulphuric  ether  is  one  of  the  most  widely  em- 
ployed substances  in  surgery  to  produce  anaesthesia ;  rt  is 
probably  the  safest  of  airanaesthetics,  except  nitrous  oxide 
gas,  and  for  this  reason  should  be  preferred  to  all  others. 
Its  effects,  according  to  Hare,  result  from  the  action  of  the 
drug,  first,  on  the  brain,  then  on  the  sensory  tracts  of  the 

16 


242  MINOR  SURGERY. 

spinal  cord,  then  on  the  motor  tracts,  then  on  the  sensory 
side  of  the  medulla  oblongata,  and  finally  upon  the  motor 
side  of  the  medulla,  and  thereby  produces  death  from  res- 
piratory failure  if  given  to  excess.  Its  administration  is 
attended  with  risk  in  the  following  cases:  (1)  In  infants, 
in  whom  it  causes  irritation  of  the  bronchial  mucous  mem- 
brane, with  profuse  secretion  of  mucus,  and  may  cause  also 
bronchopneumonia.  (2)  In  aged  persons  a  profuse  secre- 
tion of  mucus  and  bronchopneumonia  may  follow  its  use ; 
it  is  also  contraindicated  in  these  subjects  in  whom  there 
are  rigidity  of  the  chest  and  lessened  respiratory  power. 
(3)  In  advanced  organic  disease  of  the  kidneys,  and 
especially  in  nephritis  of  the  interstitial  form  with  urine 
of  a  low  specific  gravity  and  in  diabetic  subjects.  (4)  In 
disease  of  the  heart  its  administration  is  more  dangerous 
in  myocardial  than  in  valvular  lesions.  (5)  In  cases  of 
obstructed  respiration  from  swelling  of  the  pharynx,  fixa- 
tion of  the  tongue  in  cancer  and  cellulitis  of  the  neck,  and 
in  emphysema  and  abdominal  distention.  (6)  In  cases  in 
which  examination  of  the  blood  shows  that  the  haemoglobin 
is  diminished  to  less  than  50  per  cent.  (7)  When  the 
bronchial  irritation  following  its  use  may  impair  the  re- 
sult in  operations  for  hernia  and  in  laparotomy. 

Preparation  of  Patient. — A  patient  should  be  prepared 
for  the  administration  of  ether  by  withholding  all  solid 
food  for  at  least  six  hours  before  its  inhalation  ;  he  should 
be  in  the  recumbent  posture,  and  any  garments  about  the 
chest  or  neck  should  be  loosened,  so  that  the  respiratory 
movements  are  not  interfered  with.  The  surgeon  should 
see  also  that  any  false  teeth  or  foreign  bodies  which  may 
be  present  in  the  mouth  are  removed  before  the  adminis- 
tration of  the  drug  is  begun.  As  the  vapor  of  ether  often 
causes  irritation  of  the  mucous  membrane  of  the  lips  and 
nasal  passages,  it  is  well  to  anoint  these  parts  with  a  little 
vaseline  or  cold-cream  before  administering  the  ether. 

Some  surgeons  recommend  that  the  stomach,  if  it  con- 
tains food,  should  be  washed  out  by  means  of  the  stomach- 
pump,  and  insist  upon  this  washing  before  operation  in 
cases  of  intestinal  obstruction,  as  the  stomach  may  con- 


ANAESTHETICS.  243 

tain  stercoraceous  matter,  which  may  be  drawn  into  the 
respiratory  passages  if  vomiting  occurs,  and  so  cause  aspi- 
ration-pneumonia. 

It  should  also  be  borne  in  mind  that  the  vapor  of  ether 
is  very  inflammable,  and  that  it  is  heavier  than  the  air,  so 
that  lights  brought  near  the  patient  while  being  etherized 
should  be  held  at  a  higher  level  than  the  ether-can  or 
inhaler. 

The  anaesthetizer  should  always  listen  to  the  patient's 
heart  before  giving  an  anaesthetic;  this  enables  him  to 
detect  any  irregularity  in  its  action,  and  at  the  same  time 
has  a  good  moral  effect  upon  the  patient,  especially  if  he 
can  assure  him  that  he  is  in  good  condition  to  take  the 
anaesthetic. 

It  is  Avell  also  to  have  another  physician  present  during 
the  administration  of  a  general  anaesthetic,  as  unforeseen 
difficulties  occasionally  arise.  There  should  always  be  at 
hand  tongue-forceps  and  instruments  with  which  trache- 
otomy may  be  performed  if  necessary  ;  also  nitrite  of  amy], 
digitalis,  strychnine,  and  a  hypodermic  syringe. 

In  debilitated  patients  or  in  those  who  are  weak  from 
loss  of  blood  the  administration  of  half  an  ounce  to  an 
ounce  of  whiskey  from  fifteen  to  thirty  minutes  before  the 
anaesthetic  is  given  is  often  advisable. 

The  person  intrusted  with  the  administration  of  the 
anaesthetic  should  watch  the  patient  closely,  and  should  not 
have  his  attention  diverted  by  the  operation  ;  he  should 
carefully  observe  the  pulse,  respiration,  and  color  of  the 
patient's  face,  and  be  prepared  to  withdraw  the  anaesthetic 
upon  the  development  of  any  symptom  of  danger,  and  to 
treat  such  symptoms  should  they  arise. 

An  anaesthetic  should  never  be  given  to  a  woman  with- 
out the  presence  of  a  third  person,  as  in  some  cases  these 
agents  give  rise  to  erotic  dreams,  and  it  may  be  difficult 
to  disabuse  the  patient's  mind  of  the  idea  that  an  assault 
has  been  committed  unless  the  evidence  of  eye-witnesses 
at  the  time  of  the  anesthetization  can  be  brought  forward 
to  prove  that  such  was  not  the  case. 

Ether  produces  more  irritation  of  the  respiratory  tract 


1244 


MINOR  SURGERY. 


Fig.  167. 


than  chloroform,  and  its  administration  is  sometimes  fol- 
lowed by  the  development  of  bronchitis,  pulmonary  con- 
gestion, or  pneumonia.  These  complications  are  less  likely 
to  occur  if  care  is  taken  to  avoid  the  administration  of 
ether  in  patients  who  are  suffering  from  bronchial  irrita- 
tion, and  to  see  that  a  patient  who  has  taken  ether  is  not 
exposed  to  draughts  and  is  not  allowed  to  go  out  into 
cold  or  moist  air  immediately  after  recovering  from  the 
anaesthetic. 

Administration  of  Ether. — In  the  administration  of  ether, 
a  towel  folded  into  a  cone  or  one  of  the  various  ether 

inhalers  may  be  employed. 
The  best  of  these  is  Allis's 
inhaler,  which  consists  of  a 
metallic  framework  covered 
with  leather  or  a  nickel- 
plated  case,  which  carries  a 
number  of  folds  of  a  roller- 
bandage,  giving  a  large  sur- 
face for  the  rapid  evapora- 
tion of  the  drug  (Fig.  167). 
If  a  towel  folded  into  a 
cone  is  used;  a  few  layers  of 
stiff  paper  interposed  between 
the  outer  layers  of  the  towel 
will  keep  the  cone  in  shape 
and  prevent  evaporation  of 
the  ether  from  its  external  surface. 

For  the  administration  of  an  anaesthetic,  the  patient 
should  be  in  the  recumbent  posture  and  the  head  turned 
to  one  side,  as  in  this  position  mucus  is  less  apt  to  collect 
in  the  pharynx  and  interfere  with  the  breathing. 

In  administering  ether,  two  to  four  drachms  are  poured 
into  a  cone  or  inhaler  and  placed  over  the  nose  and  mouth 
of  the  patient.  He  is  then  requested  to  take  deep  breaths, 
or  to  blow  the  ether  away,  which  latter  procedure  causes 
him  to  take  deep  inspirations.  In  the  beginning  of  ether- 
ization the  patient  will  resist  the  inhalation  much  less 
vigorously  if  the  ether  is  given  slowly  with  a  plentiful  ad- 


Allis's  ether  inhaler. 


A2UESTHETICS.  245 

mixture  of  air.  The  first  effect  of  the  inhalation  of  ether 
is  to  produce  acceleration  of  the  pulse  and  respiration  ;  the 
mucous  membrane  of  the  air-passages  is  irritated,  and 
coughing  often  occurs;  there  is  also  in  this  stage  a  dispo- 
sition to  muscular  movements,  and  it  is  frequently  neces- 
sary to  restrain  the  patient;  the  brain  also  is  excited,  and 
the  patient  is  apt  to  cry  out.  These  symptoms  call  for  a 
continuance  of  the  administration  of  the  ether,  and  not  for 
its  withdrawal.  To  avoid  the  irritation  of  the  mucous 
membrane  of  the  air-passages  during  the  administration, 
it  has  been  suggested  that  the  nasal  mucous  membrane  be 

CO 

sprayed  with  a  2  percent,  solution  of  cocaine  just  before 
administration  of  the  anaesthetic,  and  this  spraying  should 
be  repeated  every  half  hour  while  the  anaesthetic  is  used. 
By  the  use  of  cocaine  in  this  manner,  the  nasal  reflexes 
are  diminished,  the  stage  of  excitement  is  shortened,  the 
sense  of  suffocation  is  diminished,  and  vomiting  is  less 
likely  to  occur.  Succeeding  the  stage  of  excitement,  if 
the  ether  be  pushed,  profound  anaesthesia  takes  place,  as 
is  evidenced  by  the  loss  of  consciousness,  relaxation  of 
the  muscular  system,  moist  skin,  loss  of  special  senses, 
contracted  pupils,  and  slow  and  deep  respiration,  tend- 
ing to  become  stertorous.  "When  the  conjunctiva  is  in- 
sensitive to  the  touch  of  the  finger,  anaesthesia  is  usually 
profound.  When  the  anaesthesia  is  complete,  the  amount 
of  ether  inhaled  should  be  diminished,  and  the  patient 
given  only  so  much  as  will  keep  him  well  under  its  influ- 
ence. It  is  surprising  how  small  a  quantity  a  careful 
and  watchful  anaesthetizer  will  require  to  keep  the  patient 
fully  under  its  effects  for  a  considerable  time.  The  time 
required  to  produce  anaesthesia  varies  in  different  cases  : 
it  is  produced  in  children  in  a  few  minutes  ;  in  adults 
from  ten  to  twenty  minutes  are  usually  required  ;  drunk- 
ards and  those  who  have  taken  ether  frequently  require 
a  larger  amount  and  a  longer  time  to  come  under  its  in- 
fluence. After  the  administration  of  the  drug  is  stopped, 
the  patient  may  continue  for  some  time  in  an  unconscious 
condition,  resembling  a  quiet  sleep,  or  he  may  awake  and 
exhibit  more  or  less  symptoms  of  cerebral  excitement. 


246  MINOR  SURGERY. 

First  Insensibility  from  Ether. — There  often  exists  in 
the  early  course  of  the  administration  of  ether  a  stage  of 
primary  anaesthesia,  which  lasts  for  a  minute  or  more, 
and  which  may  be  taken  advantage  of  to  perform  such  a 
minor  surgical  operation  as  opening  an  abscess,  reduction 
of  a  dislocation  or  a  fracture,  or  extraction  of  a  tooth. 
The  recovery  from  this  condition  is  usually  very  prompt, 
and  is  not  followed  by  nausea  or  the  after-effects  which 
attend  the  prolonged  administration  of  ether. 

Accidents  during  Etherization. — During  the  administra- 
tion of  ether,  particularly  in  the  early  stage,  the  patient 
may  suddenly  stop  breathing,  the  face  at  the  same  time 
becoming  cyanosed.  This  condition  calls  for  withdrawal 
of  the  ether;  and  if  an  inspiratory  effort  does  not  quickly 
follow,  pressure  should  be  made  upon  the  front  of  the 
chest,  and  when  this  is  relaxed  a  deep  inspiration  usually 
takes  place,  and  no  further  difficulty  is  experienced.  This 
condition  should  not  be  confounded  with  the  very  common 
effort  of  holding  the  breath,  the  latter  occurring  with  the 
chest  fully  expanded,  the  former  with  the  chest  empty. 

Vomiting  may  occur  during  etherization,  and  the  vom- 
ited matter  may  accumulate  in  the  pharynx  or  the  mouth, 
and  obstruct  the  breathing,  or  may  enter  the  larynx  or 
trachea  and  cause  a  like  result.  Vomiting  is  more  apt  to 
take  place  if  solid  food  has  been  taken  shortly  before  the 
administration  of  the  anaesthetic.  If  this  accident  occurs 
and  interferes  with  breathing,  the  jaws  should  be  opened 
and  the  head  turned  to  one  side,  when  the  vomited  matter 
will  usually  escape  without  difficulty.  If,  however,  food 
has  entered  the  larynx,  and  is  not  ejected  by  coughing,  it 
will  be  necessary  to  perform  tracheotomy  promptly  and 
hold  the  tracheal  wound  open,  or  to  introduce  a  tube  and 
practise  artificial  respiration.  The  breathing  may  also  be 
obstructed  by  the  accumulation  of  mucus  and  saliva  in 
the  pharynx.  This  is  less  likely  to  occur  if  the  head  is 
kept  to  one  side  during  the  administration  of  the  drug; 
if  it  occurs,  the  head  should  be  turned  to  one  side,  the 
jaws  opened,  and  the  material  removed  with  small  sponges 
or  pieces  of  gauze  fixed  to  sponge-holders. 


AX. ESTHETICS,  247 

The  tongue  may  fall  backward  and  obstruct  the  breath- 
ing when  muscular  relaxation  is  complete  during  anaesthe- 
sia; this  accident  is  also  less  likely  to  occur  if  the  head 

is  kept  to  one  side  during  etherization,  li'  asphyxia 
results    from    falling    back   of   the    tongue,  it    should  be 

brought  forward  by  placing  the  fingers  on  each  side 
beneath  the  angles  of  the  inferior  maxillary  bone,  and 
pushing  the  jaw  forward,  at  the  same  time  over-extending 
the  neck  by  bending  the  head  backward  (Fig.  168),  or  the 
mouth  should  be  opened  and  the  tongue  drawn  forward 
with  tongue  forceps.  Either  of  these  manipulations  is 
usually  sufficient  to  re-establish  the  respiratory  movements. 

Fig.  168. 


i 


Pushing  the  jaw  forward. 

If,  however,  in  any  of  these  forms  of  mechanical  asphyxia 
respiratory  action  is  not  promptly  restored,  some  form  of 
artificial  respiration  should  promptly  be  resorted  to,  either 
Laborde's,  Silvester's  Howard's,  or  forced  respiration  ;  and 
of  these,  Laborde's  method,  by  rhythmical  traction  of  the 
tongue,  and  Silvester's  have  yielded  the  most  satisfactory 
results.  Efforts  at  resuscitation  in  these  cases  should 
be  persevered  in  for  at  least  half  an  hour,  as  apparently 
hopeless  cases  have  been  saved  by  persistent  use  of  these 
means. 

Failure  of  respiration  may  occur  also  from  paralysis  of 


248  MINOR  SURGERY. 

the  respiratory  centres,  or  spasm  of  the  respiratory 
muscles ;  the  former  may  occur  from  an  overdose  of  the 
anaesthetic,  or  from  intercurrent  asphyxia,  syncope,  or 
morbid  states  of  the  respiratory  system. 

Spasmodic  respiratory  failure  may  occur  before  complete 
anaesthesia,  and  is  liable  to  arise  in  muscular  and  emphy- 
sematous subjects.  Respiratory  failure  from  either  of 
these  causes  should  promptly  be  treated  by  artificial  respi- 
ration and  the  hypodermic  use  of  strychnine,  atropine,  or 
digitalis. 

After-effects  of  Ether. — After  complete  anaesthesia  from 
ether,  nausea  and  vomiting  are  very  common,  and  both  are 
more  apt  to  follow  in  case  the  patient  has  taken  food 
shortly  before  the  administration  of  the  anaesthetic.  They 
may  last  for  only  a  short  time,  or  may  persist  for  hours. 
If  persistent,  the  swallowing  of  a  few  mouthfuls  of  hot 
water  will  often  relieve  the  condition  ;  or  the  administra- 
tion of  cocaine  hydrochlorate,  grain  one-quarter,  with 
crushed  ice,  repeated  two  or  three  times,  or  the  use  of 
crushed  ice  with  champagne  or  brandy,  may  be  followed 
by  satisfactory  results.  Inhalation  of  the  fumes  of  vine- 
gar will  often  prevent  nausea  and  vomiting,  the  vine- 
gar being  poured  upon  a  towel  or  a  piece  of  gauze,  which 
is  held  over  the  mouth  and  nose  of  the  patient,  and  it 
should  be  applied  as  soon  as  the  administration  of  the  ether 
is  stopped ;  it  should  be  used  continuously  for  some  time 
to  be  followed  by  the  best  results. 

Ether  and  Nitrous  Oxide  Gas. — The  production  of 
anaesthesia  by  the  combined  use  of  nitrous  oxide  gas  and 
ether  has  been  quite  extensively  employed  both  in  Eng- 
land and  this  country.  Hewitt  considers  this  method  of 
producing  anaesthesia  far  superior  to  any  other  method 
which  we  possess  at  the  present  time.  A  special  apparatus 
is  required,  which  controls  definitely  the  amount  of  nitrous 
oxide,  ether,  and  air.  Anaesthesia  is  produced  first  by  the 
use  of  nitrous  oxide  gas,  and,  as  soon  as  this  is  developed, 
the  anaesthetic  state  is  maintained  by  substituting  the  vapor 
of  ether  for  the  nitrous  oxide  gas.  Xo  air  is  given  with 
the  gas  until  anaesthesia  is  complete,  which  should  be  in 


ANJSSTHETICS.  249 

from  two  to  three  minutes.  Breathing  at  this  time  is 
stertorous,  and  cyanosis  is  well  marked.  After  this  time 
air  is  administered  with  the  ether  vapor.     Anaesthesia  by 

this  method  is  rapidly  induced,  there  is  less  struggling  and 
spasm,  the  quantity  of  ether  employed  is  smaller,  and 
the  after-effects  are  less  marked,  especially  vomiting,  and 
recovery  from  the  anaesthetic  state  is  more  rapid  than 
when  ether  is  used  alone. 

Ether  and  Oxygen. — The  administration  of  ether  with 
oxygen  gas  has  been  employed  to  a  considerable  extent. 
In  the  employment  of  this  combination  to  produce  anaesthe- 
sia the  patient  is  first  allowed  to  inhale  a  small  amount  of 
ether  from  an  inhaler,  and  a  tube  connected  with  the 
oxygen  receiver  is  then  introduced  into  the  inhaler  and 
the  oxygen  gas  turned  on,  so  that  the  patient  is  allowed 
at  the  same  time  to  inhale  the  vapor  of  ether  and  oxygen 
gas.  A  special  apparatus  may  also  be  employed  which 
regulates  definitely  the  amount  of  ether  and  oxygen  fur- 
nished. Anaesthesia  produced  by  this  combination  is 
accompanied  by  less  cyanosis,  vomiting  is  rare,  and  the 
patient  recovers  very  promptly  from  the  anaesthetic  state. 
As  the  ether  vapor  and  oxygen  form  a  highly  explosive 
mixture,  care  should  be  exercised  not  to  bring  a  flame  near 
the  patient  during  its  administration. 

Chloroform. — This  drug  according  to  Hare,  first  affects 
the  brain,  then  the  sensory  part  of  the  spinal  cord,  then 
the  motor  area  of  the  cord,  then  the  sensory  paths  of  the 
medulla  oblongata,  and  finally  the  motor  portions  of  the 
medulla,  and  produces  death  from  failure  of  the  vasomotor 
centre  and  of  the  respiratory  centre  unless,  as  rarely 
occurs,  the  heart  has  succumbed  to  the  drug. 

Chloroform  is  certainly  a  much  more  dangerous  anaes- 
thetic than  ether,  and  although  it  is  widely  used  in  the 
British  Islands  and  upon  the  Continent,  it  is  not  exten- 
sively used  in  this  country  except  in  certain  districts — as 
in  the  southern  and  southwestern  districts  of  the  United 
States,  and  here  its  use  is  followed  by  fewer  fatalities  than 
in  the  northern  districts,  so  that  it  is  possible  that  its  use 
is  safer  in  warm  climates.     Clinical  experience  has  demon- 


250  MINOR  SURGERY. 

strated  that  chloroform  may  be  used  in  aged  and  very- 
young  subjects  and  in  puerperal  patients  with  compara- 
tive safety  ;  deaths  from  chloroform  are  more  common  in 
the  middle  period  of  life.  It  is  also  to  be  preferred  to 
ether  in  patients  suffering  from  emphysema  of  the  lungs, 
bronchitis,  and  vascular  degeneration  of  the  kidneys.  It 
is  also  employed  by  some  surgeons  instead  of  ether  in 
operations  upon  the  mouth  when  the  actual  cautery  is 
used,  on  account  of  its  less  inflammable  character. 

Considerable  diversity  of  opinion  exists  among  different 
observers  as  to  whether  death  resulting  from  chloroform 
is  due  to  failure  of  the  heart  or  failure  of  the  respiration, 
and  each  has  brought  forward  a  large  amount  of  evidence 
to  prove  his  views  correct.  Although  it  has  been  demon- 
strated that  chloroform  is  a  direct  depressant  and  para- 
lyzant to  the  heart-muscle  or  its  contained  ganglia,  and 
that  cardiac  dilatation  of  varying  degrees  may  be  brought 
about  by  the  administration  of  chloroform,  yet  clinical 
experience  shows  that  paralysis  of  the  respiratory  centres 
is  probably  the  most  important  factor  in  causing  death 
during  chloroform  anaesthesia,  for  circulatory  failure  in 
these  cases  is  due  to  embarrassed  or  suspended  breathing, 
and  the  only  method  of  treatment  which  has  been  found 
of  value  is  that  which  tends  to  bring  about  respiratory 
action,  namely,  some  one  of  the  various  forms  of  artificial 
respiration. 

Chloroform  is  more  dangerous  in  the  earlier  stages  of 
the  administration,  and  the  gravity  of  the  operation  ap- 
pears to  have  little  effect  in  increasing  its  danger,  as  sta- 
tistics show  that  the  greatest  number  of  fatalities  have 
occurred  in  minor  surgical  procedures,  such  as  extracting 
teeth,  amputation  of  fingers,  reduction  of  dislocations,  and 
opening  abscesses. 

Preparation  of  Patient. — A  patient  is  prepared  for  the 
administration  of  chloroform  as  in  the  case  of  ether,  the 
same  precautions  being  taken  as  regards  the  removal  of 
false  teeth  or  foreign  bodies  from  the  mouth,  and  to  see 
that  the  clothing  about  the  chest  and  neck  does  not  re- 
strict the  circulation  or  respiratory  movements. 


ANESTHETICS. 


251 


Fig.  169. 


Administration  of  Chloroform. — Chloroform  is  adminis- 
tered by  pouring  a  drachm  of  the  drug  upon  a  folded 
towel,  which  is  first  held  a  few  inches  from  the  mouth 
and  nose,  and  gradually  brought  nearer,  but  is  not  allowed 
to  come  in  contact  with  the  face,  as  from  its  local  irritat- 
ing action  it  will  blister  the  surface  ;  the  lips  and  anterior 
nares  should  be  anointed  with  vaseline. 

The  anaesthetizer  should  remember  that  one  of  the  dan- 
gers in  the  administration  of  chloroform  is  the  risk  of  too 
great  concentration  of  its  vapor,  so  that 
he  should  see  that  a  sufficient  admixt- 
ure of  atmospheric  air  takes  place. 

Chloroform  may  also  be  administered 
with  Esmarch?s  inhaler,  which  consists 
of  a  wire  frame  covered  with  gauze 
(Fig.  169). 

Various  inhalers  have  been  devised 
to  regulate  the  amount  of  chloroform 
administered  and  to  secure  the  proper 
admixture  of  atmospheric  air,  and  the 
best  of  these  is  probably  Mr.  Clover's 
apparatus. 

Profound  chloroform  anaesthesia  is 
manifested  by  insensibility  of  the  con- 
junctiva to  the  touch,  absence  of  the 
reflexes,  complete  muscular  relaxation, 
and,  usually,  contracted  pupils.  When 
this  stage  is  reached,  the  inhalation 
should  be  stopped,  and  after  this  time  only  so  much  chlo- 
roform should  be  administered  as  is  sufficient  to  keep  the 
patient  fully  under  its  influence. 

Complete  anaesthesia  should  be  produced  before  any 
operation  is  begun  ;  if  undertaken  before  that  time,  syn- 
cope may  be  produced  by  reflex  inhibition  of  the  heart. 
If  convulsive  movements  take  place  before  the  patient  is 
fully  anaesthetized,  and  the  face  becomes  cyanosed,  the 
inhalation  should  be  discontinued  until  these  symptoms 
disappear.  The  pupils  should  also  be  watched  carefully, 
to  see  if  they   respond   to  light  or  are  contracted.     If 


Esmarch's  inhaler. 


252  MINOR  SURGERY. 

the  anaesthesia  is  not  complete,  insensibility  to  light  or 
wide  dilatation  is  a  sign  of  danger  which  calls  for  re- 
moval of  the  anaesthetic  and  active  treatment  to  stimu- 
late the  circulation  and  respiration.  If  the  inhalation 
has  been  stopped  and  is  again  in  a  short  time  resorted  to, 
it  should  be  given  very  carefully  and  slowly,  for  syncope 
may  suddenly  develop  from  the  fact  that  the  heart  or  the 
respiration  may  feel  the  effect  of  the  previous  use  of  the 
drug. 

Accidents  during  Chloroform  Anaesthesia. — Mechanical 
asphyxia  may  occur  during  anaesthesia  produced  by  chloro- 
form, as  well  as  that  by  ether,  by  obstruction  of  the  res- 
piratory passages  by  blood,  mucus,  foreign  bodies,  or  the 
tongue  falling  backward  over  the  epiglottis.  These  acci- 
dents should  be  treated  in  the  same  manner  as  when 
occurring  during  etherization. 

Death  during  the  administration  of  chloroform  may 
result  from  cardiac  syncope  or  from  respiratory  arrest, 
and  the  dangerous  symptoms  develop  so  rapidly  that  the 
greatest  promptness  is  required  to  meet  them.  The  per- 
son administering  chloroform  should  constantly  watch 
both  the  pulse  and  the  respiration,  and  should  not  for  a 
moment  have  his  attention  diverted  from  the  patient ; 
great  vigilance  is  here,  if  possible,  more  important  than 
during  the  administration  of  ether. 

Respiratory  Arrest. — During  chloroform  anaesthesia 
paralysis  of  the  respiratory  centres  may  occur,  giving  rise 
to  respiratory  arrest.  If  this  dangerous  symptom  appears, 
the  patient's  head  should  be  lowered  and  artificial  respi- 
ration promptly  employed  to  re-establish  the  respiratory 
function. 

Cardiac  syncope  developing  during  the  administration 
of  chloroform,  manifested  by  pallor,  fluttering  or  arrested 
pulse,  and  cessation  of  respiration,  should  be  treated  by 
lowering  the  patient's  head  or  inverting  the  patient,  the 
use  of  a  rapidly  interrupted  electric  current,  the  hypo- 
dermic injection  of  digitalis,  atropine,  or  strychnine,  and 
the  employment  of  artificial  respiration,  either  Silvester's, 
the  direct  method,  or  Laborde's  method ;  and,  as  in  cases 


ANAESTHETICS.  253 

of  threatened  death  from  ether,  the  treatment  should  not 
be  desisted  from  for  some  time,  as  by  persistent  employ- 
ment of  these  means  apparently  hopeless  cases  have  been 
resuscitated. 

Chloroform  and  Oxygen. — The  combined  use  of  chloro- 
form and  oxygen  is  sometimes  employed  to  produce  anaes- 
thesia. A  small  amount  of  chloroform  is  first  adminis- 
tered, and  then  the  oxygen  gas  is  introduced  into  the 
inhaler,  and  the  two  gases  are  inhaled  at  the  same  time ; 
or  a  special  apparatus  may  be  employed,  by  means  of 
which  a  definite  amount  of  each  drug  may  be  administered. 

Chloroform  and  Ether. — The  induction  of  anaesthesia 
by  the  administration  of  ether  followed  by  chloroform,  as 
recommended  by  Hewitt,  has  been  practised  in  a  large 
number  of  cases  with  satisfactory  results.  In  producing 
anaesthesia  by  this  method,  ether  is  first  given  until  anaes- 
thesia is  produced,  and  the  anaesthetic  effect  is  then  kept 
up  by  the  administration  of  chloroform.  Hewitt  considers 
it  advisable  in  this  method  of  anaesthesia  to  let  the  patient 
come  up  slightly,  so  that  there  is  conjunctival  reflex,  before 
the  chloroform  is  substituted,  and  also  advises  that  the 
operation  should  not  be  undertaken  until  that  change  has 
been  made. 

The  A.-C.-E.  Mixture. — This  mixture,  which  con- 
sists of  3  parts  of  chloroform,  1  part  of  ether,  and  1  part 
of  alcohol,  has  been  employed  by  some  surgeons  in  place 
of  ether  or  chloroform,  with  the  idea  that  the  dangers 
of  chloroform  are  diminished  by  its  combination  with 
ether  and  alcohol.  Clinical  experience,  however,  has  not 
proved  this  view  to  be  correct.  If  administered  with  as 
much  care  as  chloroform,  its  administration  is  accompanied 
with  the  same  safety.  It  should  be  administered  upon  a 
towel  or  inhaler  in  the  same  manner  as  chloroform,  and 
the  patient  should  be  watched  as  carefully  during  its  inha- 
lation as  during  the  administration  of  the  latter  drug,  and 
any  complications  occurring  should  be  treated  in  the  same 
manner  as  those  arising  during  the  use  of  chloroform. 

Schleich's  Anaesthetic  Mixture. — Schleich  has  re- 
cently introduced  an   anaesthetic  mixture  which  he  con- 


254  MINOR  SURGERY. 

siders  safer  than  ether  or  chloroform.  He  maintains  that 
the  absorption  of  a  general  anaesthetic  is  chiefly  regulated 
by  the  boiling-point  or  point  of  maximum  evaporation  of 
the  anaesthetic.  An  anaesthetic  is  unsafe  in  direct  propor- 
tion to  the  amount  absorbed,  and  the  lower  the  boiling- 
point  of  the  anaesthetic  the  less  is  absorbed  ;  hence  an 
anaesthetic  to  be  safe  should  have  a  low  boiling-point.  A 
safe  anaesthetic  is  one  in  which  the  point  of  maximum 
evaporation  is  near  the  temperature  of  the  patient,  so  that 
as  much  of  the  anaesthetic  will  be  exhaled  upon  expiration 
as  is  inhaled  on  inspiration.  Schleich  employs  three 
mixtures.  The  first  contains,  by  volume,  chloroform,  §iss  ; 
petroleum  ether,  ^ss;  sulphuric  ether,  3vj.  The  second 
contains  chloroform,  ^iss ;  petroleum  ether,  £ss  ',  sulphuric 
ether,  ^v.  The  third  contains  chloroform,  3j  ;  petroleum 
ether,  ^ss  ;  sulphuric  ether,  ^ij  siiss.  This  anaesthetic  may 
be  administered  upon  a  towel  or  inhaler.  It  is  claimed 
that  by  the  use  of  these  anaesthetic  mixtures  little  excite- 
ment is  produced  and  cyanosis  rarely  occurs  ;  that  there  is 
no  hypersecretion  of  mucus  and  no  consecutive  bronchitis 
or  pneumonia,  and  that  the  anaesthetic  state  is  quiet,  reaction 
is  rapid,  and  vomiting  occurs  in  less  than  half  the  cases. 

Bromide  of  Ethyl. — This  drug  was  introduced  as  an 
anaesthetic  some  years  ago,  but  as  a  number  of  deaths  fol- 
lowed its  use,  it  was  abandoned.  The  time  required  to 
produce  anaesthesia  is  shorter  than  for  ether,  but  there  is 
often  induced  violent  muscular  spasm,  which  renders  it  an 
unsuitable  anaesthetic  in  many  cases. 

Bromide  of  ethyl  has  again  been  revived  as  an  anaes- 
thetic, but  clinical  experience  has  proved  that  its  use  is 
not  devoid  of  danger,  that  it  is  not  as  safe  as  ether,  and 
that  it  possesses  no  advantages  in  point  of  safety  over 
chloroform.  When  used,  it  should  be  administered  by 
pouring  a  drachm  or  two  upon  an  inhaler  or  a  towel,  and 
the  patient  should  be  watched  with  the  same  care  as  dur- 
ing the  administration  of  chloroform. 

After-effects  of  Anaesthetics. — Nausea  is  not  common 
after  chloroform  anaesthesia.  The  treatment  of  this  con- 
dition   following   etherization    has    been    previously   de- 


TRUSSES.  255 

scribed.  The  temperature  is  usually  notably  lowered  by 
anaesthetics,  so  that  it  is  always  well    to  apply  artificial 

heat  and  keep  the  patient  well  covered.  A  form  of 
mental  disturbance  known  as  confusional  insanity  is  often 
attributed  to  the  use  of  anaesthetics,  but,  as  it  does  not 
usually  develop  until  some  time,  often  two  or  three  weeks, 
after  their  employment,  H.  C.  Wood  is  of  the  opinion 
that  the  relation  between  the  mental  symptoms  and  the 
anaesthetic  has  not  been  clearly  proved  in  these  cases,  and 
that  it  is  rather  the  outcome  of  a  peculiar  depression  of 
the  cerebral  cortex  produced  by  the  shock  of  the  opera- 
tion itself,  or  by  the  emotional  strain  due  to  the  surgical 
illness.  This  view  seems  to  be  confirmed  by  the  fact 
that  many  of  the  cases  of  emotional  insanity  which  are 
observed  follow  injuries  in  which  no  anaesthetic  has  been 
given.  Albuminuria  and  glycosuria  may  follow  the 
administration  of  ether  or  chloroform,  but  are  usually 
only  temporary  conditions. 

Paralysis  of  the  nerves  of  the  brachial  plexus  may  follow 
prolonged  anaesthesia  when  the  arm  is  drawn  high  above 
the  head ;  it  is  not  due  to  the  anaesthetic,  but  results  from 
stretching  of  the  nerves  over  the  head  of  the  humerus  or 
their  compression  between  the  clavicle  and  the  first  rib. 
Paralysis  of  the  museulo-spiral  nerve  may  also  occur  from 
prolonged  pressure  of  the  arm  upon  the  edge  of  the  table. 

Hypnotism. — The  anaesthetic  state  of  hypnotism  has 
been  utilized  for  the  performance  of  surgical  operations. 
Schmeltz  and  others  have  recorded  operations  done  under 
this  influence,  the  patient  apparently  suffering  no  pain. 
While  there  is  no  doubt  that  the  anaesthetic  state  can  be 
obtained  by  hypnotism,  which  might  be  serviceable  in 
surgical  operations,  yet  we  do  not  believe  that  it  will  be 
of  general  utility. 

TRUSSES. 

A  truss  for  the  palliative  treatment  of  hernia  is  a 
mechanical  contrivance  with  one  or  more  pads  and  a 
strap  :  these  are   held  in  position  by  a  spring  to  which 


256  MINOR  SURGERY. 

they  are  attached,  which  holds  the  pad  in  contact  with  the 
skin  over  the  hernial  opening. 

Trusses  are  usually  applied  in  cases  of  reducible  and 
sometimes  in  irreducible  hernise,  and  are  used  in  the  treat- 
ment of  hernias  at  all  ages  ;  in  infants  and  young  children 
the  continued  use  of  a  properly  fitting  truss  is  often  fol- 
lowed by  a  radical  cure  of  the  hernia.  They  are  made 
with  steel  or  rubber  springs  and  with  pads  of  wood, 
rubber,  celluloid,  or  horsehair,  covered  with  chamois  skin; 
their  shape  and  the  pressure  which  they  should  exert  vary 
with  the  variety  of  hernia  for  which  they  are  applied. 

A  firm  compress  applied  over  the  inguinal  canal  or 
crural  ring,  secured  in  position  by  a  firmly  applied  spica- 
of-the-groin  bandage,  forms  a  very  satisfactory  temporary 
means  of  preventing  the  descent  of  a  hernia. 

A  properly  fitting  truss  should  be  worn  without  dis- 
comfort to  the  patient — that  is,  should  not  make  too 
much  pressure  upon  the  skin  at  the  points  where  the  pads 
are  applied,  and  should  absolutely  prevent  the  descent  of 
the  hernia.  In  testing  the  adequacy  of  a  truss,  after 
application,  to  prevent  the  escape  of  the  hernia,  the 
patient  should  be  instructed  to  separate  his  legs,  bend  for- 
ward over  the  back  of  a  chair,  and  cough  or  strain  forcibly ; 
if  this  does  not  bring  the  hernia  down,  control  of  the  rupt- 
ure may  be  considered  satisfactory. 

Trusses  should  be  applied  after  the  complete  reduction 
of  the  hernia,  while  the  patient  is  in  the  recumbent  pos- 
ture. When  first  applied,  the  truss  should  be  worn  both 
during  the  night  and  day ;  and  if  the  skin  becomes  tender 
at  the  points  of  pressure,  it  should  be  sponged  with 
alcohol  and  alum,  then  dried  and  dusted  with  powdered 
starch  or  lycopodium.  Patients  at  first  sometimes  com- 
plain of  discomfort  in  wearing  a  truss,  but  they  soon 
become  accustomed  to  its  presence.  After  a  truss  has  been 
worn  for  some  time,  its  use  at  night,  while  the  patient  is 
in  bed,  may  be  dispensed  with,  but  the  patient  should  not 
remove  it  until  he  is  in  bed  in  the  recumbent  posture,  and 
he  should  reapply  it  before  he  rises  in  the  morning.  In 
children  it  is  better  to  have  the  truss  worn  continuously  ; 


TR  USSES. 


257 


and  if  it  is  removed  for  bathing,  the  nurse  should  be 
instructed  to  place  her  finger  over  the  ring  to  prevent  de- 
scent of  the  hernia  until  the  truss  is  applied.  In  apply- 
ing trusses  to  male  children  care  should  be  taken  not  to 
make  pressure  upon  an  undescended  testicle. 

Trusses  for  Inguinal  Hernia. — In  measuring  a  patient 
for  this  form  of  truss*  the  circumference  of  the  body  mid- 
way between  the  crest  of  the  ilium  and  the  great  trochan- 
ter should  be  taken,  and  the  distance  from  the  symphysis 
pubis  to  the  anterior  superior  spinous  process  of  the  ilium 
may  also  be  given,  as  half  of  this  distance  corresponds  to 
the  position  of  the  internal  abdominal  ring.  In  reducible 
inguinal  hernia  the  truss-pressure  should  be  exerted  upon 
the  inguinal  canal  and  directly  backward.     To  control  this 


Fig.  170. 


Fig.  171. 


Truss  for  inguinal  hernia. 


Hood's  truss. 


variety  of  hernia,  a  single-spring  truss  (Fig.  170)  may  be 
employed,  or  the  use  of  a  truss  having  a  double  spring 
with  flat  pads  on  each  side  of  the  spine  attached  to  the 
springs,  and  a  smaller  pad  over  the  inguinal  canal  on  the 
unaffected  side,  with  a  full  pad  on  the  side  of  the  hernia, 
will  often  be  efficient.  This,  which  is  known  as  Hood's 
truss,  is  one  which  will  be  found  a  very  satisfactory  in- 
strument both  in  inguinal  and  femoral  hernia  (Fig.  171). 
Trusses  for  Femoral  Hernia. — In  measuring  a  patient 
for  this  variety  of  truss,  the  circumference  of  the  body 
midway  between  the  crest  of  the  ilium  and  the  great  tro- 
chanter should  be  taken  ;  the  distance  of  the  saphenous 
opening  from  the  symphysis  pubis,  as  well  as  from  the 
anterior  iliac  spine,  should  also  be  taken.     In  reducible 

17 


258  MINOR  SURGERY. 

femoral  hernia  the  truss-pressure  should  be  directed  back- 
ward against  the  femoral  canal,  and  the  pad  should  be 
large  enough  to  make  pressure  upon  the  adjacent  tissues 
through  which  the  hernia  passes,  as  well  as  upon  the  re- 
laxed tissues  covering  the  femoral  canal.  As  in  inguinal 
hernia,  either  a  single  or  a  double  spring  truss  may  be  em- 
ployed (Fig.  172). 

In  applying  a  truss  for  femoral  hernia,  care  should  be 
taken  to  see  that  the  pad  does  not  rest  upon  the  pubis, 
and  thus  remove  the  pressure  from  the  crural  ring  and 
adjacent  tissues  and  prevent  the  proper  control  of  the 
hernia. 

Trusses  for  Umbilical  Hernia. — In  measuring  a  patient 
for  this  variety  of  truss,  the  circumference  of  the  body 
over  the  umbilicus  should  be  taken.  In  reducible  um- 
bilical hernia  the  truss-pressure  should  be  directed  back- 
ward, and  the  pad  should  bear  rather  on    the  tendinous 

Fig.  172.  Fig.  173. 


Hood's  truss  for  femoral  hernia.  Truss  for  umbilical  hernia. 

margins  of  the  ring  than  on  the  hernial  opening.  A 
truss  for  this  variety  of  hernia  should  have  a  flat  or 
slightly  convex  pad,  which  is  held  in  position  over  the 
umbilical  ring  by  means  of  springs  having  counter-pads 
on  either  side  of  the  spine  attached  to  their  extremities ; 
these  are  fastened  together  by  a  strap  (Fig.  173). 

A  simple  and  satisfactory  truss  for  umbilical  hernia  in 
infants  consists  of  a  penny  covered  by  adhesive  plaster,  or 
a  small  flat  compress  of  linen,  held  over  the  umbilical  ring 
by  one  or  two  strips  of  adhesive  or  rubber  plaster  about 
two  inches  in  width,  or  by  a  broad  strip  of  perforated 
rubber  adhesive  plaster,  which  should  be  applied  so  as  to 
cover  in  about  the  anterior  two-thirds  of  the  circumfer- 
ence of  the  body.      A  penny,  or  a  small   flat  compress 


CATHETERS  A XI)   BOUGIES.  259 

of  linen,  will   be  found  much  more  satisfactory  than  the 
conical  rubber  or  cork  pad  often  recommended. 

Trusses  for  Irreducible  Hernia. — The  application  of 
a  truss  to  this  variety  of  hernia  protects  it  from  injury 
and  prevents  its  further  protrusion.  Such  trusses  are 
secured  in  the  same  way  as  those  for  reducible  hernia, 
but  the  pads  are  made  concave  or  cup-shaped,  or  may 
have  an  air-cushion  or  water-cushion  attached  to  the  pad. 


CATHETERS    AND    BOUGIES. 

Catheters  are  hollow  tubes,  made  either  of  metal,  India- 
rubber,  or  other  flexible  substances. 

Sterilization  of  Catheters  and  Bougies. — To  avoid 
infection  of  the  bladder,  it  is  important  that  catheters  and 
bougies  should  be  sterilized  thoroughly  before  being  intro- 
duced (see  page  155). 

Infection  of  the  bladder  may  occur  from  matter  con- 
tained in  the  urethra,  so  that  this  canal  should  also  be 
sterilized  (see  page  152).  If  it  is  possible,  the  patient  should 
pass  the  urine  to  wash  out  the  urethra,  and  a  solution  of 
boric  acid  or  a  borosalicylic  solution  should  be  injected 
before  the  instrument  is  passed. 

To  lubricate  the  instrument,  sterilized  boroglyceride, 
olive  oil,  glycerin,  or  lubrichondrin  should  be  employed. 

Metallic  Catheters. — These  are  made  of  silver,  or,  if 
constructed  of  other  metals,  they  should  be  plated  with 
silver  or  nickel,  to  give  them  a  smooth,  bright  surface 
which  can  easily  be  kept  perfectly  clean  ;  and  their  shape 
should  conform  to  that  of  the  normal  urethra  (Fig.  174). 
The  shape  of  the  metallic  catheter  is  sometimes  changed 
to  meet  certain  indications ;  for  instance,  for  use  in  cases 
of  enlarged  prostate  it  is  longer  and  has  a  larger  curve 
than  the  ordinary  instrument  (Fig.  175).  The  metallic 
female  catheter  is  shorter  and  has  a  much  smaller  curve 
than  the  instrument  used  for  the  male  urethra.  A  female 
catheter  made  of  glass  is  now  frequently  employed,  and 
has  the  advantage  of  easy  sterilization. 


260 


MINOR  SURGERY. 


Flexible  Catheters. — The  most  commonly  used  variety 
of  flexible  catheter  is  that  known  as  the  English  cathe- 


Fig.  174. 


Fig.  175. 


Fig.  176. 


Fig.  177. 


Metallic  catheter. 


Prostatic  catheter. 


French  flexible      Mercier's 

catheters.  elbowed 

catheter. 


ter,  which  is  made  of  linen  and  shellac,  and  is  provided 
with  a  stylet;  it  can  be  moulded  into  any  shape  desired 
by  dipping  it  into  hot  water,  which  renders  it  flexible, 


CATHETERS  AND  BOUGIES.  261 

and,  after  moulding  it  to  the  proper  curve,  this  can  be 
fixed  by  immersing  it  in  cold  water,  which  hardens  it 
again. 

The  French  flexible  catheter  is   made  of  India-rubber, 

or  a  combination  of  this  material  with  other  substances. 
These  instruments  are  conical 
toward  their  extremities,  and 
terminate  in  an  olive-shaped 
point;  they  are  provided  with 
one  or  two  smoothly  finished 
eyes  near  the  vesical  ex- 
tremity (Fig.   176). 

Another    form    of   flexible 
catheter,    known   as    the    el- 
bowed   catheter  or  Mercier's  soft  rubber  cathete^ 
catheter    (Fig.    177),  has   an 

angle  or  elbow  near  its  vesical  extremity ;  this  is  often 
found  a  satisfactory  instrument  to  use  in  cases  of  enlarged 
prostate.  A  variety  of  flexible  catheter  made  of  soft 
India-rubber  is  also   sometimes  employed  (Fig.  178). 

Catheters  and  bougies  are  made  according  to  a  certain 
scale.  The  English  scale  runs  from  Xo.  1  to  No.  12; 
the  American,  from  Xo.  1  to  No.  20 ;  and  the  French, 
from  Xo.  1  to  Xo.  40. 

Bougies  and  Sounds. — Bougies. — These  are  flexible 
instruments  which  correspond  in  size  and  shape  to  the 
English  and  French  catheters ;  and  besides  there  are  the 
acorn-pointed  bougie  (Fig.  179)  and  the  filiform  bougie, 
which  latter  is  made  of  whalebone  or  of  the  same  material 
as  the  ordinary  French  bougie  and  catheter.  These  in- 
struments are  of  very  small  diameter,  and  may  often  be 
passed  through  strictures  which  will  admit  no  other  form 
of  instrument  (Fig.  180). 

Sounds. — These  are  solid  instruments,  usually  of  steel, 
with  a  smooth  surface  and  plated  with  nickel ;  they  corre- 
spond in  size  and  have  the  same  curve  as  the  metallic 
catheter ;  the  handle  is  flattened,  to  allow  the  operator  to 
grasp  them  firmly  ;  they  are  employed  in  the  treatment  of 
strictures  by  dilatation  (Fig.   181).     The  sound  used  in 


262 


MINOR  SURGERY. 


dilating  strictures  of  the  meatus  is  straight,  and  is  shorter 
than  the  sound  employed  in  the  treatment  of  urethral 
strictures   (Fig.   182).     A  metallic  sound  with  a  shorter 


Fig.  179. 


Fig.  180. 


Fig.  181. 


Fig.  182. 


/ 


Bulbous  or  acorn- 
pointed  bougies. 


Filiform 
bougies. 


Steel  sound. 


Sound  for  dilating 
meatus. 


curve  than  the  ordinary  sound  is  used  for  exploration  of 
the  bladder  for  calculus  or  tumor. 

Introduction  of  a  Catheter. — For  the  introduction  of 
a  catheter,  the  patient  may  be  in  the  standing,  sitting,  or 


INTRODUCTION  OF  A   CATHETER 


263 


recumbent  posture — the  latter  is  the  best  in  most  cases  ; 
he  should  resl  squarely  on  his  back,  and  have  the  thighs 
a  little  Hexed  and  separated. 

Before  passing  a  metallic  catheter,  the  surgeon  should  see 
that  it  has  been  sterilized,  and  after  warming  and  oiling  it 
he  stands  upon  the  left  side  of  the  patient  and  grasps  the 

Fig.  183. 


Introdurtion  <>f  a  ratheter.     (Voillemier.) 

penis  with  the  left  hand,  and  turns  it  over  the  pubis  and 
introduces  the  beak  of  the  catheter  into  the  meatus,  and 
gently  passes  it  along  the  urethra  until  its  point  passes 
beneath  the  symphysis  pubis ;  at  this  point  the  handle  is 
elevated  and  gently  depressed  between  the  thighs,  when 
the  beak  will  pass  into  the  bladder  (Fig.  183). 


261  MINOR  SURGERY. 

In  passing  a  catheter  in  case  of  enlarged  prostate,  when 
the  prostatic  region  is  reached  difficulty  is  sometimes  ex- 
perienced in  the  further  passage  of  the  instrument ;  this 
ma)7  be  overcome  by  introducing  the  finger  into  the  rectum 
and  guiding  the  catheter  through  the  prostatic  urethra  ;  or 
if  the  prostate  is  found  much  enlarged,  the  catheter  should 
be  withdrawn,  and  a  prostatic  catheter  (Fig.  175)  substi- 
tuted. The  same  manipulation  is  practised  in  passing 
metallic  sounds. 

Flexible  catheters  and  bougies  are  passed  by  grasping 
the  penis  and  holding  it  in  such  a  position  that  it  is  at 
a  right  angle  to  the  axis  of  the  body,  and  the  catheter 
or  bougie  is  introduced  into  the  meatus  and  conducted 
through  the  urethra  into  the  bladder  by  gently  pushing 
the  instrument  downward.  In  this  variety  of  instrument, 
which  has  no  curve,  the  surgeon  has  no  means  of  guiding 
the  point  of  the  instrument,  and  if  an  obstruction  is  met,  he 
should  withdraw  the  instrument  slightly  and  make  another 
attempt ;  all  manipulations  should  be  extremely  gentle. 

Passing  the  Female  Catheter. — It  was  formerly  con- 
sidered important  to  pass  the  female  catheter  without 
exposing  the  patient.  At  the  present  time  it  is  rarely 
done,  as  it  is  considered  more  important  to  sterilize  the 
vulva  and  region  of  the  orifice  of  the  urethra  to  avoid 
infection  of  the  bladder.  After  washing  the  vulva  with 
soap  and  water,  and  irrigating  it  with  boric  solution  or 
normal  salt  solution,  the  orifice  of  the  urethra  is  exposed, 
by  separating  the  nymphse,  and  the  catheter  is  introduced 
into  the  bladder. 

Catheterization  of  the  Ureters  in  the  Female. — In 
performing  this  operation  by  the  direct  or  Kelly's  method, 
the  patient  is  placed  in  the  dorsal  position  with  the  pelvis 
elevated  or  in  the  genu-pectoral  position,  and  the  urethra  is 
dilated  to  admit  a  cylindrical  speculum  12  to  15  millimetres 
in  diameter.  With  the  aid  of  a  head-mirror  the  interior 
of  the  bladder  can  be  directly  inspected.  The  opening  of 
the  ureter  may  be  exposed  by  turning  the  speculum  thirty 
degrees  to  one  side,  and  is  recognized  as  a  small  depres- 
sion, the  mucous  membrane  being  of  a  darker  color  than 


SECURING   CATHETER   TN  BLADDER.  265 

elsewhere.  A  delicate  elastic  or  silver  catheter  can  be 
introduced  into  this  opening,  and  by  can-fid  manipulation 
may  I"'  passed  to  the  pelvis  of  the  kidney.  By  this  pro- 
cedure, unilateral  or  bilateral  disease  of  the  kidneys  may 
be  clearly  demonstrated,  as  well  as  the  condition  of  the 
ureters  themselves.  Delicate  bougies  passed  into  the 
ureters  may  be  used  to  locate  their  position  in  the  opera- 
tion of  hysterectomy.  Catheterization  of  the  male  ureters 
can  also  be  practised. 

Tying  the  Male  Catheter  in  the  Bladder.— When  it 
is  desirable  to  retain  a  catheter  for  some  time  in  the  male 
bladder,  it  is  necessary  to  secure  it,  to  prevent  its  slipping 
out.  Either  a  metallic  or  flexible  catheter  may  be  em- 
ployed ;  but,  as  a  rule,  the  flexible  instrument  is  the  most 
comfortable  to  the  patient,  and  is  to  be  preferred  ;  there 
are  several  methods  of  securing  it  in  the  bladder. 

By  one  method,  two  narrow  strips  of  tape  or  two  or  three 
strong  silk  ligatures  are  attached  to  the  rings  at  the  end  of 
a  metallic  catheter,  or  are  securely  fastened  around  the  end 
of  the  flexible  instrument;  these  are  next  brought  back- 
ward, one  on  each  side  of  the  penis,  and  the  skin  is  drawn 
forward  and  a  strip  of  adhesive  plaster  half  an  inch  in 
width  is  passed  over  the  strings  or  tapes  and  carried  three 
or  four  times  around  the  body  of  the  penis  just  behind  the 
glans.  If  the  -kin  has  been  brought  well  forward  before 
the  strips  have  been  applied,  the  ligatures  are  tightened 
as  it  slips  back,  and  the  cathe- 
ter has  not  too  much  play  Fig. 18^- 
(Fig.  184). 

Another  method  consists  in 
fastening  a  strong  silk  ligature 
around  the  catheter  just  in  ad- 
vance of  the  meatus  ;  the  two         -  fi 
ends    are  next  brought   back-       :^j 
ward  and  tied  in  a  knot  behind 
the  corona  glandis  :  the  ends       Tying  in  catheter,   (bryaht.) 
are    then    carried    around    the 

penis  behind  the  corona  and  tied  on  one  side  of  the  frsenum ; 
the  foreskin  is  slipped  forward  and  covers  the  ligatures. 


266 


MINOR  SURGERY. 


A  catheter  may  also  be  secured  in  the  bladder  by  tying 
the  ends  of  the  silk  ligatures,  which  are  attached  to  the 
instrument  in  advance  of  the  meatus,  to  tufts  of  pubic  hair. 
Another  method  of  securing  the  catheter  is  to  perforate 
the  free  end  with  a  needle  armed  with  a  double  ligature 
of  silk  or  hemp ;  the  needle  being  removed,  two  loops  are 
made  of  the  proper  length,  and  these  are  passed  through 
the  ends  of  a  T-bandage,  which  is  secured  around  the  waist, 
the  tails  being  brought  up  on  either  side  of  the  scrotum  and 
secured  to  the  body  of  the  bandage  passing  around  the  waist. 
In  the  female,  when  it  is  desirable  to  keep  the  bladder 
empty,  the  self-retaining  catheter  is  usually  employed, 
which  consists  of  a  catheter  with  a  bulb  at  its  vesical 
extremity,  or  an  ordinary  catheter  with  silk  loops,  and  a 
T-bandage  may  be  employed  in  the  same  manner  as  in 
securing  a  male  catheter. 

Irrigation  of  the  Bladder. — This  procedure  may  be 
required  in  the  treatment  of  cystitis  or  in  sterilizing  the 
bladder,  and  is  accomplished  by  passing  a  flexible  cath- 
eter with  a  large  eye  into  the  bladder,  or 
a  double  or  two-way  catheter  may  be  em- 
ployed. A  syringe,  or,  better,  a  rubber 
bulb  holding  about  a  pint,  having  a  noz- 
zle and  stopcock  (Fig.  185),  is  filled  with 
warm  water,  or  with  any  medicated  solu- 
tion which  is  desired,  and  it  is  then  at- 
tached to  the  free  end  of  the  catheter  and 
the  contents  are  gently  injected  into  the 
bladder ;  care  should  be  taken  that  the 
bladder  is  not  too  much  distended.  When 
the  desired  amount  of  fluid  lias  been  in- 
jected, it  is  allowed  to  run  out  of  the  cath- 
eter, and  the  procedure  may  be  repeated 
until  the  solution  comes  away  perfectly 
clear. 

The  bladder  may  also  be  irrigated  with- 
out  using  a  catheter,  the  resistance  of  the  compressor  mus- 
cle of  the  urethra  being  overcome  by  the  pressure  of  a  col- 
umn of  water.    The  patient  sits  in  a  chair  and  a  rubber  or 


Fig.  185. 


Rubber  bag  with 
stopcock, for  irriga- 
tion of  the  bladder. 


I  'R  ETHR.  1 L   IXJECTIOXS. 


267 


glass  oozzle  with  a  large  bulbous  tip,  which  closely  fits  the 
meatus.  Is  inserted  into  it ;  the  nozzle  is  connected  byarubber 
tube  with  a  reservoir  containing  the  fluid  for  irrigation.  The 
reservoir  is  raised  to  a  height  of  three  to  six  feet  above  the 
patient.  He  is  directed  to  take  deep  inspirations,  and  soon 
the  bladder  becomes  tilled  with  water,  when  the  nozzle  is 
removed,  and  the  patient  empties  the  bladder  naturally. 
In  some  eases  a  little  time  is  required  before  the  column 
of  water  overcomes  the  resistance  of  the  compressor  muscle, 
or  its  entrance  into  the  bladder  may  be  hastened  by  direct- 
ing the  patient  to  attempt  to  urinate. 

Care  should  be  taken  to  see  that  the  bladder  is  perfectly 
emptied  of  the  solution,  and  in  cases  of  paralysis  of  the 
viscus  gentle  pressure  should  be  made  upon  the  abdomen 
over  the  pubis  to  accomplish  this  object.  Solutions  of 
boric  acid  and  permanganate  of  potassium,  and  weak  solu- 
tions of  carbolic  acid  and  of  nitrate  of  silver  are  often 
employed  in   washing  out  the  bladder  in  chronic  cystitis. 

Urethral  Injections. — In  the  treatment  of  urethral 
inflammations,  the  injection  of  medicated  solutions  is  gen- 
erally made  use  of ;  and  as  these  injections 
are  usually  made  by  the  patient  himself,  he 
should  be  shown  or  instructed  how  to  em- 
ploy them.  A  rubber  syringe  having  a 
conical  nozzle,  and  holding  about  two  or 
three  drachms,  is  the  best  instrument  to 
employ  for  this  purpose  (Fig.  186).  The 
syringe  having  been  filled  with  the  solution, 
the  patient  sits  upon  the  edge  of  a  hard 
chair,  with  the  thighs  separated,  grasps  the 
syringe  between  the  thumb  and  middle 
finger  of  the  right  hand,  the  tip  of  the 
index  finger  resting  upon  the  end  of  the 
piston,  and  inserts  its  conical  end  from  a 
quarter  to  half  an  inch  within  the  meatus, 
which  is  held  open  bv  the  thumb  and  finger  shape  of  nozzle  of 

a  •  V  urethral  sTnusre. 

of  the  left   hand.     After  the   introduction 

of  the  nozzle  of  the  syringe  the  tissues  should  be  pressed 

tightly  around  it,  the  pressure  being  made  laterally,  so  as 


Fig.  1S6. 


268  MINOR  SURGERY. 

to  narrow  the  urethral  opening  instead  of  broadening  it, 
as  is  the  case  when  compression  is  made  in  an  antero-pos- 
terior  direction.  After  the  fluid  has  been  thrown  into  the 
urethra  in  this  manner,  the  syringe  is  removed,  and  the 
patient  is  instructed  to  hold  the  lips  of  the  meatus  together 
for  one  or  two  minutes,  to  prevent  escape  of  the  fluid. 

Urethral  irrigation  may  also  be  practised  by  means  of 
gravity,  a  short  rubber  or  glass  tube,  or  a  glass  urethral 
nozzle  being  connected  by  a  rubber  tube  with  a  reservoir 
containing  the  fluid  to  be  used,  the  reservoir  being  placed 
slightly  above  the  patient. 

SUTURES. 

A  variety  of  materials  are  employed  for  sutures,  such 
as  silk,  catgut,  silver  or  iron  wire,  silkworm-gut,  kan- 
garoo-tail tendon,  and  horsehair.  The  materials  most  fre- 
quently employed  at  the  present  time  are  either  catgut, 
silk,  or  silkworm-gut,  although  some  surgeons  prefer 
silver  wire.  Catgut  and  kangaroo-tail  tendon  are  practi- 
cally the  only  substances  employed  which  are  absorbable ; 
the  other  varieties  of  suture  require  removal  after  their 
application,  although  some  sutures,  such  as  the  silk,  if 
absolutely  sterile,  when  buried  in  wounds  may  be  cut 
short,  as  they  are  apt  to  become  encysted  and  remain  in- 
definitely in  the  tissues.  It  matters  little  what  variety 
of  material  be  employed  for  suturing  if  the  surgeon  is 
careful  to  see  that  it  is  rendered  thoroughly  aseptic  before 
being  brought  in  contact  with  the  wound. 

Sutures  of  Relaxation. — These  sutures  are  entered  and 
brought  out  at  some  distance  from  the  edges  of  the  wound, 
and  are  employed  to  prevent  dangerous  tension  upon  the 
sutures  which  approximate  the  edges  of  the  skin.  This 
form  of  suture  is  employed  in  the  quilled,  button,  or  plate 
suture. 

Sutures  of  Coaptation. — These  are  superficial  sutures 
applied  closely  together,  and  include  only  the  skin  ;  they 
are  employed  to  secure  accurate  apposition  of  the  cuta- 
neous surface  of  wounds. 


SUTURES.  269 

Sutures  of  Approximation. — These  sutures  are  applied 
deeply  into  the  tissue  to  seeure  approximation  of  the  deep 
portions  of  a  wound  ;  this  objeet  is  accomplished  by  the 
use  of  the  quilled,  buried,  button,  or  plate  suture. 

Secondary  Sutures. — These  sutures  are  applied  when  the 
surfaces  of  the  wounds  are  covered  by  granulations,  when 
the  primary  sutures  have  failed  to  secure  apposition  of  the 
edges  of  the  wound,  in  cases  of  secondary  hemorrhage 
where  the  opening  of  the  wound  has  been  necessitated  to 
turn  out  the  blood-clot  and  secure  the  bleeding  vessel,  and 
in  plastic  operations  where  the  primary  sutures  have  failed 
to  secure  adhesions  of  the  edges  of  the  flaps.  They  are 
also  employed  with  advantage  in  closing  wounds  in  cases 
in  which  it  was  necessary  to  pack  the  wound  with  anti- 
septic gauze,  or  to  allow  haemostatic  forceps  to  remain 
clamped  upon  bleeding  tissues  in  the  wound  at  the  time  of 
operation.  The  sutures  should  in  such  a  case  be  intro- 
duced and  loosely  tied  at  this  time,  and  when  the  packing 
or  forceps  is  removed  at  the  end  of  two  or  three  days  the 
sutures  are  tightened  so  as  to  secure  apposition  of  the 
edges  of  the  wound. 

Surgical  Needles. — Needles  for  surgical  use  are  of 
different  sizes  and  shapes  (Fig.  187) ;  straight  needles  are 

Fig.  187. 


Surgical  needles. 


the  ones  commonly  employed,  but  curved  needles  will  be 
found  most  convenient  for  the  introduction  of  sutures 
in  wounds  in  certain  locations.     Hagedorn  needles,  which 


270 


MINOR  SURGERY. 


are  flat  and  have  sharp-cutting  edges,  make  a  narrow 
linear  wound  in  the  tissues,  and  are  useful  in  some 
cases.  For  the  introduction  of  sutures  in  the  intestines 
or  hollow  viscera,  the  ordinary  sewing-needle  is  generally 
employed,  as  it  does  not  cut  the  tissues,  but  merely  sepa- 
rates them,  and  its  puncture  is  not  likely  to  bleed.  Tubu- 
lar needles  are  often  employed  in  introducing  sutures  in 
wounds  in  which  the  use  of  an  ordinary  needle  is  diffi- 
cult :  for  instance,  in  the  operation  for  cleft  palate,  and  for 
the  introduction   of  sutures  in  deep  wounds,  a  mounted 

Fig.  188. 


Mounted  needle. 

needle  will  often  be  found  very  useful  (Fig.  188).  Rev- 
erdin's  needle,  which  consists  of  a  handled  needle  with  an 
eye  which  is  closed  with  a  slide,  is  useful  in  passing  deep 
sutures.     The  needle  is  first  passed  through  the  tissues, 

Fig.  189. 


Needle-holder. 


then  threaded  and  withdrawn,  carrying  the  suture  with 
it.  Needles  should  be  sharp  and  clean,  and  should  be 
rendered  thoroughly  aseptic  before  being  used.  Needles 
should  be  sterilized  by  boiling,  and  may  be  preserved  in  a 
saturated  solution  of  carbonate  of  sodium  or  albolene  to 
prevent  rusting.     A   needle-holder  is   often  required  for 


sutci:/:s. 


271 


the  satisfactory  introduction  of  sutures  in  wounds  in  cer- 
tain Localities  |  Fig.  1<S<.>  | :  it'  this  is  not  at  hand,  the  needle 
may  be  held  by  a  pair  of  dressing-forceps  or  a  pair  «»t* 
haemostatic  forceps. 

Method  of  Securing  Sutures  and  Ligatures. — 
Metallic  sutures  are  usually  secured  by  twisting  the  ends 

together  or  by  passing  the  ends  through  a  perforated  shot 

and  clamping  the  shot  with  a  shot-compressor,  which 
securely  fixes  them. 

Sutures  and  ligatures  of  catgut,  silk,  silkworm-gut, 
kangaroo- tail  tendon,  or  horsehair  are  secured  by  tying, 
and  several  different  knots  are  employed  to  secure  them. 

Reef  or  Flat  Knot. — This  is  one  of  the  best  forms  of 
knot  to  use  in  securing  sutures  or  ligatures,  and  it  is 
made  by  passing  one  end  of  the  thread  over  and  around 
the  other  end,  and  the  knot 
thus  formed  tightened  ;  the 
ends  of  the  thread  are  next 
carried  toward  each  other  and 
the  same  end  is  again  carried 
over  and  around  the  other, 
and  when  the  loop  is  drawn 
tight  we  have  formed  the  reef 
or  flat  knot  (Fig.  190). 

Surgeon's   Knot. — This   knot 
is  formed  by  carrying  one  end  Reef  or  flat  knot. 

of  the  thread  twice  around  the  other  end  (Fig.  191);  and 
after  tightening  this   loop   the   same  is  carried  over  and 

Fig.  191. 


Fig.  190. 


;ureeon's  knot. 


around  the  other  end  as  in  the  case  of  the  final  knot  of 
the  reef  or  flat  knot.     The  surgeon's  knot  and  reef  knot 


272 


MINOR  SURGERY. 


combined  is  one  of  the  best  methods  of  securing  sutures 
or  ligatures  of  catgut  or  silk,  as  the  first  knot  is  not  apt 
to  relax  before  the  second  knot  is  applied  (Fig.  192). 


Fig.  192. 


Surgeon's  knot  and  reef  knot  combined. 

Granny  Knot. — This  method  of  tying  the  ligature  or 
suture  should  not  be  employed,  as  the  resulting  knot  is 
not  as  secure  as  the  reef  knot  and  is  apt  to  relax  :  it  differs 
from  the  latter  in  the  fact  that  one  end  of  the  thread  hav- 
ing been  carried  across  and  around  the  other  end,  the  knot 
is  completed  by  carrying  the  same  end  under  and  around 
the  other  end  of  the  thread  (Fig.  193). 

Staffordshire  Knot. — This  is  much  used  to  secure  the 
pedicle  in  the  removal  of  abdominal  tumors,  and  is  applied 


Fig.  193. 


Fig.  194. 


Granny  knot. 


Staffordshire  knot. 


as  follows  :  A  handled  needle  armed  with  a  stout  silk  liga- 
ture is  passed  through  the  pedicle,  and  then  withdrawn  so 
as  to  leave  a  loop  on  the  distal  side ;  this  loop  is  drawn 
over  the  tumor,  and  one  of  the  free  ends  is  passed  through 
it  so  that  one  end  is  above  while  the  other  end  is  below  the 
retracted  loop  (Fig.  194).     The  ends  are  then  seized  and 


SUTURES. 


273 


drawn  through  the  pedicle;  at  the  same  time  the  thumb 
and  forefinger  arc  pressed  against  it  until  sufficient  con- 
striction is  made,  and  the  ends  are  finally  secured  by  tying 
as  in  the  securing  of  an  ordinary  ligature. 


Fig.  195. 


Varieties  of  Sutures. 

The  Interrupted  Suture.— This  variety  of  suture, 
which  is  the  one  most  usually  employed  in  the  apposi- 
tion of  wounds,  consists  of  a  number  of  single  stitches, 
each  of  which  is  entirely  independent  of  those  on  either 
side.  In  applying  this  suture,  the  surgeon  holds  the  edge 
of  the  wound  with  the  fingers  or  forceps  and  thrusts  the 
needle,  previously  threaded,  through  the  skin  three  or  four 
lines  from  the  edge  of  the  wound.  He 
then  passes  the  needle  from  within  outward 
through  the  tissues  of  the  opposite  flap  at 
the  same  distance  from  the  edge  of  the 
wound  (Fig.  195).  Each  stitch  is  secured 
as  soon  as  it  is  passed — by  tying  if  a  silk, 
catgut,  or  silkworm-gut  suture  be  used,  or 
by  twisting  if  a  silver  wire  suture  is  em- 
ployed. 

A  suture  may  be  used  with  a  needle 
threaded  on  each  end,  in  which  case  both 
needles  are  passed  from  within  outward. 
The  sutures  may  be  secured  as  soon  as  ap- 
plied, or  they  may  be  left  unsecured  until 
a  sufficient  number  have  been  introduced, 
and  then  they  may  be  secured  by  tying  or 
twisting.  Care  should  be  taken  to  see  that 
they  make  no  tension  on  the  edges  of  the  wound,  and  that 
they  are  so  introduced  as  to  make  the  best  possible  apposi- 
tion of  the  parts. 

Buried  Sutures. — In  extensive  and  deep  wounds  it  may 
be  found  necessary  to  introduce  both  deep  and  superficial 
sutures,  the  former  bringing  about  apposition  of  the  mus- 
cles and  deep  fascia,  the  superficial  layer  bringing  together 
the  superficial  fascia  and  skin. 

18 


Interrupted  su- 
ture.  (Park.) 


274 


MINOR  SURGERY. 


Fig.  196. 


Deep  or  buried  sutures  are  often  employed  to  unite 
fascia,  muscles,  or  tendons,  and  the  best  material  for  this 
variety  of  suture  is  either  catgut,  silk, 
silkworm-gut,  or  kangaroo-tail  tendon. 
Continued  Suture. — This  variety  of 
suture  is  applied  in  the  same  manner  as 
the  interrupted  suture,  but  the  stitches 
are  not  cut  apart  and  tied ;  it  is  made  with 
silk  or  catgut,  and  is  secured  by  draw- 
ing it  double  through  the  last  stitch  and 
using  the  free  end  to  make  a  knot  with 
the  double  portion  attached  to  the  needle 
(Fig.  196).  This  suture  may  be  used 
in  intestinal  wounds,  but  may  also  be 
employed  in  obtaining  apposition  of  the 
edges  of  wounds  in  tissues  of  loose 
structure. 

Subcuticular  Suture. — Halsted  has 

introduced  a  suture  in  which  the  needle 

is  introduced  on  the  under  surface  of  the  skin  on  one  side, 

and  brought  out  just  beneath  the  cut  edge;  it  is  then  entered 


Continued  or  glovers' 
suture.    (Park.) 


Fig.  197. 


Subcuticular  suture. 


in  the  reverse  direction  below  the  epidermic  surface  oppo- 
site;   when  tied,  it  will  lie  wholly  out  of  sight.      The 


SUTURES.  -11') 

object  of  this  variety  of  suture  is  to  avoid  infection  of 
the  wound  by  the  skin  coccus,  which  may  be  introduced 
by  the  suture  if  passed  from  without  inward.  Fine  silk 
or  catgut  should  be  used  for  this  variety  of  suture,  which 
may  become  encysted,  absorbed,  or  gradually  cast  off 
after  a  few  weeks.  If  employed  as  a  continuous  suture, 
the  free  ends  may  be  tied  together,  and  the  suture  subse- 
quently removed  by  cutting  the  loop  and  drawing  out  the 
suture  from  one  end  of  the  wound  (Fig.  197). 

The  Twisted  or  Hare-lip  Suture. — This  is  a  very 
useful  form  of  suture  where  great  accuracy  and  firmness 
of  apposition  of  the  edges  of  the  wound 
are  desired.     It  is  applied   by  thrusting  Fig.  198. 

pins  or  needles  deeply  through  both  lips  ^ 

of  the  wound,  the  edges  being  kept  in  B=lI|IjK|JP=:^ 
contact  over  the  wound  by  figure-of-eight  jJJiL^ 

turns  with  silk  or  wire  (Fig.   198).     The       ^SSj^^-^, 
ends  of  the  pins  should  be  cut  off  with  pin-        ^^PPSiP' 
cutters    after  the  sutures  are  applied,  or     Twisted  or  hare.lip 
should  be  protected  by  pieces  of  cork  or  suture, 

plaster  to  prevent  them  from  injuring  the 
skin  of  the  patient  and  causing  him  pain.     The  twisted  or 
hare-lip  suture  is  frequently  employed  in   plastic  opera- 
tions about  the  face  and  in  other  parts  of  the  body  where 
accurate  apposition  of  the  flaps  is  important. 

Mattress  or  Quilt  Suture. — This  suture  is  applied  by 
carrying  the  needle  through  the  two  flaps  and  then  back 
again,  so  that  a  loop  is  left  on  one  side  and  the  two  ends 
of  the  suture  project  from  the  opposite  flap  (Fig.  205). 
This  variety  of  suture  may  be  applied  as  an  interrupted 
or  as  a  continuous  suture ;  in  the  latter,  loops  are  made 
through  the  flaps  on  each  side  of  the  wound. 

The  Quilled  Suture. — In  making  use  of  this  suture,  a 
needle  armed  with  a  double  thread  of  wire  or  silk  is 
passed  through  the  tissues  as  in  applying  the  interrupted 
suture,  but  at  a  greater  distance  from  the  edges  of  the 
wound.  Into  the  loops  on  one  side  of  the  wound  is  inserted 
a  quill  or  piece  of  a  flexible  catheter  or  bougie,  and  on  the 
opposite  side  the  free  ends  of  the  sutures  are  tied  around  a 


276 


MINOR  SURGERY. 


similar  object  after  being  tightened  (Fig.  199).    This  form 
of  suture  makes  deep  equable  pressure  along  the  whole 


Fig.  199. 


The  quilled  suture.    (Smith.) 

line  of  the  wound.  In  applying  this  suture,  it  may  be 
found  advisable  in  some  cases  to  introduce  a  few  superfi- 
cial interrupted  sutures  along  the  line  of  the  wound  to 

secure  accurate  approximation  of  the 
Fig.  200.  skin.     Two  small  rolls  of  sterilized 

or  antiseptic  gauze  may  be  used  as  a 
substitute  for  the  quills  or  pieces  of 
catheter,  as  shown  in  Fig.  200. 

Button  or  Plate  Suture. — This 
suture  is  applied  by  passing  a  needle 
armed  with  a  double  thread  as  in 
the  case  of  the  quilled  suture,  the 
ends  of  the  suture  being  passed 
through  the  eyes  of  a  button  or 
through  perforations  in  a  lead  plate 
before  being  threaded  in  the  eye  of 
the  needle.  After  the  suture  pre- 
pared in  this  way  has  been  passed 
through  both  sides  of  the  wound,  the 
needle  is  removed  and  the  free  ends 
of  the  suture  are  passed  through  the 
eyes  of  a  button  or  the  perforations  in  a  lead  plate  on  the 


Modified  quilled  suture. 
(Park.) 


SUTURES. 


277 


opposite  side  of  the  wound,  and  are  tightened  and  secured 
(Fig.  201).  In  applying  this  form  of  sutures,  small  rolls 
of  antiseptic  gauze  may  be  used  instead  of  buttons,  as 
shown  in  Fig.  202.  This  form  of  suture  may  be  employed 
in  deep  wounds  to  accomplish  the  same  purpose  as  the 
quilled  suture.  It  allows  the  cutaneous  margins  of  the 
wound  to  remain  free  from  compression,  and  here,  as  in 
the  case  of  the  quilled  suture,  a  few  interrupted  sutures 
may  be  introduced  between  the  button  or  plate  sutures  to 
secure  accurate  apposition  of  the  skin  surfaces  if  desired. 


Fig.  201. 


Fig.  202. 


Button  suture.  (Smith.) 


Modified  plate  suture,  using  gauze  pledgets. 
(Park.) 


Shotted  Suture. — This  suture  receives  its  name  not 
from  any  special  method  of  application,  but  solely  from 
the  way  in  which  it  is  secured  ;  any  of  the  previously 
mentioned  varieties  of  sutures  may  be  employed.  The  ma- 
terial used  in  applying  this  suture  may  be  catgut,  silver 
wire,  silkworm-gut,  silk,  or  horsehair,  and  after  the  suture 
has  been  passed  the  needle  is  removed,  and  the  ends  are 
passed  through  a  perforated  shot ;  the  ends  are  then  drawn 
upon  to  bring  the  edges  of  the  wound  in  contact,  and  the 
shot  is  pressed  down  to  the  skin  and  clamped  by  means  of 
a  shot-compressor.  The  suture  is  then  cut  off  flush  with 
the  surface  of  the  shot. 

This  method  of  securing  sutures  is  especially  useful  in 


278  MINOR  SURGERY. 

closing  wounds  in  the  mucous  cavities,  such  as  the  vagina, 
rectum,  and  mouth,  where  the  knot  or  twist  of  the  wire 
might  cause  irritation  of  the  surface  or  pain  to  the  patient ; 
it  is  also  a  useful  method  of  securing  sutures  in  plastic 
operations ;  it  also  facilitates  the  removal  of  the  sutures,  as 
the  shot  is  not  apt  to  be  obscured  by  the  swollen  tissue, 
and  is  easily  seized  by  forceps  when  the  loop  is  divided. 

Removal  of  Sutures. — Where  sutures  are  buried  in 
the  tissues  or  used  to  approximate  parts  in  cavities  which 
are  subsequently  closed,  such  materials  should  be  used  for 
sutures  as  will  be  absorbed  in  a  few  days,  or  will  become 
encysted,  and  remain  harmless  in  the  tissues — such  as  cat- 
gut, silkworm-gut,  or  silk — and  it  is  needless  to  state  that 
sutures  used  with  this  end  in  view  should  be  rendered  per- 
fectly aseptic  before  being  employed. 

Catgut  sutures,  when  well  prepared  and  used  for  sutures 
in  external  wounds,  usually  undergo  absorption  in  from 
ten  to  fifteen  days ;  the  loop  buried  in  the  tissues  is  ab- 
sorbed, and  the  knot  may  be  removed  from  the  surface 
with  forceps  or  it  may  come  off  with  the  dressings. 

The  other  substances,  such  as  silk,  silkworm-gut,  silver 
wire,  and  horsehair,  are  removed  by  cutting  one  side  of 
the  loop  and  making  traction  upon  the  knot  of  the  suture 
with  forceps,  or  in  the  case  of  the  wire  suture,  after  divid- 
ing the  loop  and  straightening  out  one  end  of  it,  the  wire 
should  be  withdrawn  in  a  curved  direction. 

Sutures  which  are  not  causing  irritation  should  be  al- 
lowed to  remain  until  the  wound  is  solidly  healed.  The 
time  usually  required  for  their  retention  in  cases  of  aseptic 
wounds  is  from  eight  to  twelve  days. 

Intestinal  Sutures. 

Lembert's  Suture. — Lembert's  suture  is  used  in  wounds 
of  the  viscera  covered  by  the  peritoneum,  with  the  object 
of  bringing  in  contact  the  peritoneal  surfaces.  This  form 
of  suture  is  usually  employed  in  closing  wounds  of  the 
intestine,  bladder,  or  stomach. 

A    needle   armed  with  a  fine  catgut  or  silk  thread  is 


INTESTINAL  SUTURES. 


279 


passed,  and  it  is  better  to  employ  a  round  needle,  such  as 
the  ordinary  sewing-needle,  in  preference  to  the  bayonet- 
pointed  needle,  as  there  results  by  its  use  less  bleeding 

Fig.  203.  Fig.  204. 


Lembert's  suture.    (Brya>~t.) 


Lernbert's  suture,    a,  serous  :  b,  muscu- 
lar: and,  c,  mucous  coat,     i  Smith.) 


Fig.  205. 


from  the  punctures.  The  needle  is  first  carried  through 
the  peritoneal  and  muscular  coats  of  the  intestine  a  short 
distance  from  the  wound,  and 
it  is  then  carried  across  the 
wound  and  passed  through  the 
same  portions  of  the  intestine  a 
short  distance  from  the  edge  of 
the  wound  on  the  opposite  side 
(Fig.  203),  and  when  the  suture 
is  tightened  the  peritoneal  sur- 
faces of  the  intestine  are  inverted 
and  brought  into  contact  with 
each  other  (Fig.  204) ;  the  inter- 
rupted or  continued  suture  may 
be  employed  in  making  this 
form  of  suture. 

Halsted's  Mattress  or  Quilt 
Suture. — This  is  a  modifica- 
tion of  Lembert's  suture.  The  needle  penetrates  the  peri- 
toneal and  muscular  coats  of  the  gut,  including  a  small 
portion  of  the  submucosa,  twice  on  each  side  of  the  wound, 
and  is  then  tied  (Fig.  205). 


Halsted's  quilt  suture  for  intestine. 


280 


MINOR  SURGERY. 


Ozerny  Suture. — This  suture  is  applied  in  intestinal 
wounds  by  passing  the  needle  armed  with  a  catgut  or  silk 
thread  through  the  serous  membrane  on  one  side  of  the 
wound  of  the  intestine  and  out  at  the  wound  surface  so  as 
not  to  include  the  mucous  membrane ;  the  needle  is  then 
passed  through  the  wound  surface  on  the  opposite  side, 
avoiding  the  mucous  membrane,  and  brought  out  through 
the  serous  membrane  a  short  distance  from  the  edge  of 
the  wound.  By  this  suture  the  lips  of  the  wound  are 
approximated.  For  additional  security  in  preventing 
escape  of  the  contents  of  the  intestine  and  to  secure  ap- 
proximation of  the  serous  surfaces  a  few  Lembert  sutures 
should  be  introduced. 


METHODS  OF  INTESTINAL  ANASTOMOSIS. 

Circular  Suture  of  Intestine. — After  division  or  resec- 
tion of  the  intestine  the  ends  may  be  united  by  sutures. 

Fig.  206. 


Circular,  or  end-to-end  suture  of  the  intestine.    (Richardson.) 

Interrupted  Lembert  sutures  are  usually  employed.     The 
sutures  should  first  be  applied  at  the  mesenteric  border, 


THE  MURPHY  BUTTON. 


281 


and  great  care  should  be  exercised  to  make  the  apposition 
close  at  this  point.  The  ends  of  the  bowel  should  then 
be  brought  together  with  closely  applied  Lembert  sutures. 
If  the  mesentery  has  been  divided,  it  should  also  be  ap- 
proximateed  by  sutures  (Fig.  206). 


Fig.  207. 


The  Murphy  button. 


The  Murphy  Button. — This  is  a  mechanical  contrivance 
which  may  be  employed  to  secure  end-to-end  apposition  of 


Fig.  208. 


The  two  portions  of  the  Murphy  button  held  in  place  by  purse-string  sutures. 

(Richardson.) 

the  divided  intestine,  or  may  be  used  to  form  a  lateral 


282 


MINOR  SURGERY. 


anastomosis  between  the  intestines  or  hollow  viscera. 
The  construction  of  the  button  is  shown  in  Fig.  207. 
This    method    of    end-to-end    approximation    or    anasto- 


Fig.  209. 


End-to-end  union  of  intestine  with  Murphy's  buttou.     (Krhardsox,) 

mosis  can  be  accomplished  with  accuracy  and  with  great 
rapidity.  In  employing  the  button  for  these  purposes,  it  is 
separated  into  its  two  parts,  and  each  part  is  slipped  into 

Fig.  210. 


^V™vlt 


■  m 


wiM/iii,, 


wh  mi  lb II 

End-to-end  approximation,  button  in  position.     (Richardson.) 


the  divided  end  of  the  intestine  and  secured  by  a  purse- 
string  suture  (Fig.  208),  and  the  parts  are  approximated 
by  fastening  the  two  portions  of  the  button  together  (Figs. 


LATERAL  ANASTOMOSIS.  283 

209  and  210).  Where  lateral  anastomosis  between  the 
intestines,  or  between  the  intestine  and  another  hollow 
visens,  is  desired,  an  incision  is  made  in  each  organ,  and 
half  of  the  button  is  slipped  into  each  opening  and  secured 
by  a  purse-string  suture,  and  the  portions  of  the  button  are 
then  fastened  together.  Union  of  the  peritoneal  surfaces 
results,  and  the  button  is  usually  released  in  from  ten  to 
twelve  days  by  sloughing  of  the  included  tissues,  and  is 
passed  by  the  anus. 

Senn's  Method. — When  it  is  desired  to  form  a  perma- 
nent orifice  between  two  portions  of  the  gut  or  other 
hollow  viscera,  the  ends  of  the  gut  are  closed,  and  an 
opening  is  made  in  each   portion  of  the  gut,  into  which 

Fig.  211. 


V///^//////////////sy///////^^^^ 


INTESTINE 


\!00f%Zf^///-ir//Mvy///sM^^^ 


WALL  OF 
INTESTINE 
TURNED  IN   AND 
SECURED   BY      /jF 
LEMBERT  STSTCHEsCf 


Showing  position  of  bone  plates  in  intestinal  anastomosis  alter  resection 
of  the  bowel.     (Roberts.) 

the  perforated  bone  plates  of  decalcified  bone  are  slipped, 
and  the  walls  of  the  gut  surrounding  the  openings  are 
held  in  contact  with  each  other  by  sutures  attached  to  the 
perforated  plates ;  this  is  the  method  devised  by  Senn. 
The  manner  of  using  the  bone  plates  and  sutures  is  shown 
in  Fig.  211.  To  accomplish  the  same  purpose,  rubber 
rings  or  perforated  plates  of  rubber  have  been  employed  ; 
also  rings  made  from  catgut,  to  which  the  sutures  are 
attached,  in  the  same  manner  as  Senn's  plates,  and  if 
catgut  rings  are  employed,  these  will  be  softened  and  dis- 
solved in  a  short  time  so  as  to  be  passed  without  difficulty. 
Abbe's  Method  of  Lateral  Anastomosis. — Portions 


284 


MINOR  SURGERY. 

Fig.  212. 


Lateral  anastomosis.    First  stage  of  operation.    (Richardson.) 
Fig.  213. 


Lateral  anastomosis;  operation  completed.    (Richardson.) 


END-TO-END  APPROXIMATION.  285 

of  the  intestinal  tract  more  or  less  distant,  or  the  intestine 
and  the  stomach,  may  be  united  by  this  procedure,  thus 
permitting  the  contents  to  pass  through  the  new  opening. 
The  bowel  upon  each  side  of  the  constricted  portion  is 
manipulated,  so  that  both  portions  lay  side  by  side;  or,  in 
case  a  portion  of  the  bowel  has  been  removed,  the  ends 
are  inverted  and  closed  by  Lembert's  sutures.  The  two 
portions  of  the  bowel  are  brought  side  by  side,  and  a 
longitudinal  cut  three  inches  in  length,  opposite  the  mes- 
enteric attachment,  is  made  through  the  coils  to  be  united. 
The  posterior  edges  of  the  incision  should  first  be  brought 
together  by  continuous  or  interrupted  sutures  (Fig.  212). 

The  margins  of  the  incision  may  be  hemmed  before 
uniting  them.  The  anterior  edges  of  the  incision  are  next 
united  by  another  continuous  stitch,  and  for  additional 
security  a  second  line  of  interrupted  or  continuous 
sutures  may  be  applied  (Fig.  213).  The  time  required 
for  the  application  of  the  sutures  is  one  disadvantage  of 
this  operation. 

Intestinal  anastomosis  by  this  method  may  be  employed 
instead  of  the  circular  suture  in  wounds  completely  divid- 
ing the  intestine,  and  after  resection  of  the  intestine  for 
the  removal  of  growths  or  for  stricture. 

Anastomosis  or  End-to-end  Approximation  by  La- 
place's Forceps. — Laplace  has  recently  devised  a  forceps 
by  which  end-to-end  approximation  or  lateral  anastomosis 
can  be  accomplished  with  great  accuracy  and  rapidity. 
The  forceps  are  of  different  sizes  according  to  the  parts 
to  be  united,  and  consist  of  two  parts,  which  are  really 
haemostatic  forceps  curved  into  a  semicircle  on  each  side 
and  held  together  by  means  of  a  clasp  ;  they  open  as  two 
rings  (Fig.  21 4).  They  hold  together  the  parts  to  be  united, 
and  serve  the  same  purpose  as  Semi's  bone  plates,  keeping 
the  serous  surfaces  in  contact.  The  sutures  are  intro- 
duced at  all  points  except  where  the  forceps  penetrate  the 
parts  that  are  sutured.  The  sutures  having  been  intro- 
duced, the  forceps  are  released  by  loosening  the  clasp  and 
withdrawing  the  forceps,  first  one  half  and  then  the  other 
half,  and  the  small  opening  is  finally   closed  by  one  or 


286 


MINOR  SURGERY. 


two  sutures.     These  forceps  may  be  used  in  end-to-end 
approximation,  lateral  anastomosis,  or  gastroenterostomy. 

Fig.  214. 


Anastomosis  forceps.    (Laplace.) 


The  forceps  devised  by  O'Hara  and  by  Allis  are  less  com- 
plicated and  have  been  used  with  equally  good  results. 


LIGATURES    USED    IN    THE    TREATMENT    OF    VAS- 
CULAR GROWTHS. 


Various  forms  of  ligatures  are  used  for  the  strangulation 
of  vascular  growths  ;  the  material  employed  is  usually 
strong  silk  or  hemp  thread,  catgut,  or  silver  wire. 

The  Single  Ligature  with  a  Pin.— This  is  applied  by 


DOUBLE  LIGATURE. 


287 


first  inserting  a  hare-lip  pin  through  the  skin  near  the  edge 
of  the  growth,  passing  it  under  the  growth  and  bringing 
it  out  through  the  skin  at  a  point  opposite  the  plaee 
of  entry  ;  a  strong  silk  or  hemp  ligature  is  passed  under 
the  ends  of  the  pin  surrounding  the  base  of  the  tumor,  and 
is  drawn  tight  enough  to  strangulate  the  growth,  and  is 
secured  by  two  knots  (Fig.  215).     If  the  growth   is  of 

Fio.  21 5. 


Vascular  tumor  strangulated  with  pin  and  ligature. 

considerable  size,  it  is  better  before  applying  this  ligature 
to  introduce  a  second  pin  at  right  angles  to  the  first  one, 
and  then  secure  the  ligature  under  the  pins.  In  applying 
these  forms  of  ligature  to  healthy  skin,  the  patient  is  saved 
much  pain,  and  the  separation  of  the  mass  is  hastened,  by 
cutting  a  groove  in  the  skin  with  a  sharp  knife  at  the 
point  wThere  the  ligature  is  to  be  applied ;  the  ligature 
when  tied  is  buried  in  the  groove  thus  made. 

Fig.  216. 


Method  of  applying  double  ligature.    (Roberts.  > 


Double  Ligature. — This  ligature  is  applied  by  passing 
a  needle  or  a  needle  w7ith  a  handle,  armed  with  a  double 
ligature,  through  the  skin  near  the  growth,  and  then  pass- 


288 


MINOR  SURGERY. 


Fig.  217. 


Method  of  applying  double  liga 
ture  and  pin.  (Bryant.) 


ing  it  under  the  tumor  and  bringing  it  out  through  the  skin 

at  a  point  directly  opposite  the 
point  of  insertion  ;  the  ligature 
is  then  divided  and  the  needle 
removed.  The  tumor  is  strangu- 
lated by  tying  firmly  the  corre- 
sponding ends  of  the  ligature  on 
each  side  of  the  tumor,  each  liga- 
ture including  one-half  of  the 
growth  (Fig.  216). 

The  double  ligature  may  also 
be  applied  by  first  passing  a  pin 
under  the  growth  and  then  pass- 
ing a  needle  armed  with  a  double 
thread  under  the  tumor  at  right 
angles  to  the  pin,  and  after  re- 
moving the  needle  the  ends  of  the 
ligature  are  tied  and  the  tumor 
is  strangulated  in  two  sections 
(Fig.  217). 

Quadruple  Ligature. — In  applying  this  ligature,  two 
needles  carrying  a  double  thread  are  passed  under  the 
growth  at  right  angles  to  each  other;  or  if  the  handled 
needles  be  used,  they  may  first  be  passed  in  this  manner, 
and  then  threaded  with  double  ligatures,  which  are  carried 
under  the  growth  as  they  are  withdrawn.  The  needles 
being  removed,  the  surgeon  ties  two  ends  of  the  ligature 
together,  and  repeats  this  procedure  until  the  growth  has 
been  strangulated  in  four  sections. 

Subcutaneous  Ligature. — This  is  applied  by  intro- 
ducing a  needle  armed  with  a  ligature  through  the  skin 
near  the  growth,  and  carrying  it  through  the  subcutaneous 
tissues  around  the  part  to  be  constricted  for  a  short  distance, 
then  bringing  it  out  through  the  skin.  The  needle  is  again 
introduced  through  the  same  puncture,  and  is  again  brought 
out  through  the  skin  at  some  distance  from  the  first  point 
of  exit.  It  is  next  introduced  through  this  puncture  and 
brought  out  at  a  more  distant  point.  In  this  way  the 
growth  is  completely  encircled  by  a  subcutaneous  ligature^ 


ELASTIC  Lid  A  TUBES. 


289 


which  is  finally  brought  out  at  the  point  of  entrance  ;  the 
tumor  is  strangulated  by  firmly  tying  together  the  ends  of 
the  ligature  (Fig.  218). 

If  a  needle  armed  with  a  double  ligature  is  first  passed 
under  the  growth,  the  ligature  is  divided,  and  by  passing 
each  end  of  the  divided  ligature  subcutaneously  around 

Fig.  218. 


Method  of  applying  subcutaneous  ligature.     (Holmes.) 


the  growth  it  may  be  strangulated  subcutaneously  in  two 
sections. 

Erichsen's  Ligature. — This  ligature  is  employed  to 
strangulate  tumors  of  irregular  shape  in  a  number  of  sec- 
tions. A  strong  silk  or  hemp  ligature  three  yards  in 
length,  one-half  of  which  is  stained  black,  is  carried  by  a 
needle  as  a  double  ligature  under  the  growth  at  various 
points  so  as  to  leave  a  series  of  loops  about  nine  inches 
long  on  each  side  of  the  tumor  (Fig.  219) ;  the  black  loops 
being  cut  on  one  side,  the  white  on  the  other,  the  ends  are 
then  firmly  tied  so  as  to  strangulate  the  growth  in  sections 
(Fig.  220). 

Elastic  Ligatures. — Ligatures  made  of  India-rubber 
varying  from  half  a  line  to  several  lines  in  thickness  are 
often  made  use  of  in  surgery.  They  may  be  employed 
to  strangulate  growths  such  as  moles  or  nsevi,  or  in  the 
treatment  of  fistulse,  and  are  especially  useful  in  the  treat- 

19 


290 


MINOR  SURGERY. 


merit  of  those  cases  of  fistula  in  ano  in  which  the  internal 
opening  into  the  bowel  is  situated  high  up,  as  the  division 

Fig.  219. 


Method  of  applying  Erichsen's  ligature.    (Erichsen.) 

of  such   fistula?   by   this   means   is  accomj^lished   without 
hemorrhage  and  with  less  risk  than  by  the  employment 

Fig.  220. 


Erichsen's  ligature  applied. 

of  the  knife.  In  applying  elastic  ligatures  in  such  cases, 
the  ligature,  after  being  passed  through  the  fistula  by 
means  of  a  probe,  is  carried  out  through  the  internal 
opening ;  the  sphincter  is  next  well  stretched,  and  the 
elastic  ligature  is  then  firmly  tied  with  two  or  three  knots; 
the  greater  the  tension  made   before  the  ligature  is  tied 


TREATMENT  OF  HEMORRHAGE.  291 

the  more  rapidly  will  it  cut  its  way  out.  The  smaller 
sizes  of  rubber  drainage-tubes  may  be  substituted  for  the 
solid  rubber  ligatures. 


TREATMENT  OF  HEMORRHAGE. 

The  surgeon  may  be  called  upon  to  treat  the  following 
varieties  of  hemorrhage  :  arterial,  venous,  or  capillary; 
and  these  again  are  classified  according  to  the  time  of 
their  occurrence,  as  'primary — that  is,  bleeding  which 
occurs  at  the  time  the  wound  is  inflicted ;  intermediary  or 
consecutive,  that  which  occurs  within  twenty-four  or  forty- 
eight  hours  after  the  reception  of  the  injury,  and  which 
generally  takes  place  during  the  period  of  reaction  ;  and 
secondary,  which  usually  results  from  a  septic  condition  of 
the  wound,  causing  a  septic  arteritis,  and  occurs  usually 
after  forty-eight  hours,  but  may  occur  at  any  time  subse- 
quent to  this  period  until  the  wound  is  healed.  The 
treatment  of  hemorrhage  is  both  constitutional  and  local. 

Constitutional  Treatment. — This  consists  in  keeping 
the  patient  in  the  recumbent  posture  and  avoiding  any 
sudden  elevation  of  the  head  or  arms  which  might  induce 
fatal  svncope.  Opium  is  a  valuable  remedy  and  should  be 
freely  used.  Ergot,  gallic  acid,  acetate  of  lead,  and  tinct- 
ure of  iron  may  also  be  employed,  and  stimulants  and 
food  should  be  carefully  administered  ;  in  extreme  cases 
the  intravenous  injection  or  infusion  of  normal  salt  solu- 
tion should  be  resorted  to.  The  haemostatic  properties  of 
gelatin  have  led  to  its  use  by  subcutaneous  injection  in 
various  forms  of  internal  hemorrhage.  A  sterilized  aque- 
ous solution,  containing  2  per  cent,  of  gelatin  in  normal 
salt  solution,  is  injected  into  the  loose  cellular  tissue  of 
the  abdominal  walls  or  buttock,  about  200  c  c.  being  em- 
ployed. It  has  been  used  in  haemoptysis,  epistaxis,  and 
in  intestinal  hemorrhage  in  typhoid  fever. 

Local  Treatment. — This  consists  in  the  adoption  of 
various  local  measures  to  control  the  bleeding,  which  may 
be  either  temporary  or  permanent  in  their  action. 


292 


MINOR  SURGERY. 


Temporary  Control  of  Arterial  Hemorrhage. 

This  may  be  effected  by  pressure  applied  directly  to 
the  bleeding  vessel  in  the  wound  or  by  pressure  applied 
indirectly  to  the  main  artery  between  the  point  of  its 
injury  and  the  centre  of  the  circulation,  and  this  pressure 
may  be  made  by  the  fingers — digital  compression — by  co?/i- 
jyresses,  or  by  means  of  tourniquets. 

Digital  Compression. — This  constitutes  one  of  the 
most  valuable  means  employed  in  the  temporary  control 
of  hemorrhage :   the  finger  is  pressed  directly  upon  the 

Fig.  221. 


fite?-rw-, ;.,-., 


Digital  compression  of  the  femoral  artery. 

bleeding  vessel,  in  the  wound,  or  is  used  to  make  pressure 
upon  the  artery  from  which  the  bleeding  arises  at  some 
point  between  the  wound  and  the  centre  of  the  circulation 
(Fig.  221).  Control  of  hemorrhage  by  digital  pressure 
can  be  maintained  only  for  a  few  minutes,  for  the  fingers 
of  the  surgeon  or  assistant  soon  become  tired,  so  that  it 
is  employed  only  until  means  are  adopted  for  permanent 
arrest  of  the  bleeding.  Digital  compression  of  the  radial 
and  ulnar  arteries  may  be  resorted  to  for  the  control  of 
hemorrhage  during  amputations  of  the  fingers,  of  the 
axillary  and  femoral  arteries  in  amputations  at  the  shoul- 
der-joint and  the  hip-joint.     It  is  also  used   to  control 


TOURNIQUETS. 


293 


hemorrhage  from  wounds  either  tho  result  of  aecident  or 
those  made  by  the  knife  of  the  surgeon,  in  which  case 
the  finger  is  placed  directly  upon  the  divided  vessel  or  is 
employed  to  hold  a  sponge  or  compress  firmly  in  the  wound. 
Compresses. — By  the  use  of  compresses  placed  directly 
in  the  wound  or  applied  to  the  vessel  between  the  wound 
and  the  centre  of  the  circulation,  the  temporary  control  of 
hemorrhage  may  be  very  satisfactorily  accomplished.  The 
compress  which  is  applied  in  the  wound  should  be  made  of 
antiseptic  or  aseptic  gauze,  thereby  diminishing  the  chances 
of  wound-infection.  The  compress  should  be  held  in 
position  by  a  bandage  firmly  applied,  and  is  generally 
employed  only  as  a  temporary  expedient  until  a  more 
permanent  means  of  controlling  the  bleeding  is  adopted. 

Fig.  222. 


Petit's  tourniquet. 


Tourniquets. — These  instruments,  which  are  employed 
for  the  temporary  control  of  hemorrhage  from  wounds,  are 
of  many  different  kinds. 


294  MINOR  SURGERY. 

Petit's  Tourniquet. — This  consists  of  two  metal  plates 
connected  by  a  strong  linen  or  silk  strap,  with  a  buckle, 
the  distance  between  the  plates  being  regulated  by  a  screw 
(Fig.  222).  In  applying  this  tourniquet,  a  compress  or 
roller-bandage  is  placed  directly  over  the  artery  to  be 
compressed,  and  may  be  held  in  position  by  a  few  turns 
of  the  bandage.  The  lower  plate  of  the  tourniquet  is 
placed  directly  over  this  pad,  and  the  strap  is  tightly 
secured  around  the  limb  to  keep  the  instrument  in  place. 
The  screw  is  then  turned  so  as  to  separate  the  plates  and 
tighten  the  strap,  thus  forcing  the  compress  or  pad  upon 
the  artery  and  controlling  its  circulation.  This  instru- 
ment is  very  generally  employed  for  the  control  of  hem- 
orrhage in  wounds  of  the  extremities,  and  is  especially 
useful  in  amputation  of  these  parts,  being  placed  over 
the  main  artery  some  distance  above  the  seat  of  opera- 
tion. 

The  Spanish  Windlass. — An  improvised  tourniquet, 
known  as  the  Spanish  windlass,  may  be  employed  in  cases 
of  emergency  ;  it  is  prepared  by  folding  a  handkerchief  or 
piece  of  muslin  into  a  cravat  and  placing  a  compress  or 
smooth  pebble  on  the  body  of  the  cravat ;  this  is  placed 
over  the  artery  to  be  controlled,  and  the  ends  of  the  hand- 
kerchief are  tied  loosely  around  the  limb ;  a  short  stick  is 
passed  through  this  loop,  and  by  twisting  the  stick  the  loop 
is  tightened  and  the  compress  is  forced  down  upon  the 
artery  (Fig.  223). 

Many  other  forms  of  tourniquet  have  been  devised  which 
have  the  pad  and  counter- pad  arranged  to  make  pressure 
upon  the  vessel,  such  as  Lister's  aorta  compressor  (Fig. 
224),  which  is  employed  in  the  treatment  of  aneurism  of 
the  iliac  vessels  and  for  the  control  of  hemorrhage  in  ampu- 
tation at  the  hip-joint.  Signorini's  tourniquet  (Fig.  225) 
is  constructed  upon  the  same  principle,  and  is  frequently 
employed  to  control  the  circulation  in  the  femoral  artery 
in  cases  of  operations  on  the  thigh  and  leg  and  in  the 
treatment  of  femoral  or  popliteal  aneurism. 

Elastic  Constriction. — The  elastic  tube,  or  the  strap 
of  Esmarch's  apparatus  (Fig.  226),  may  also  be  employed 


ELASTIC  CONSTRICTION. 


295 


for  the  temporary   control   of  arterial   hemorrhage,  being 
applied  above  the  wound  :  and  if  it  is  not  at  hand,  any 

strong  rubber  cord  or  a  piece  of 
Fig.  223.  large-sized  drainage-tube  may  be 

used  as  a  substitute.  Elastic  sus- 
penders or  garters  may  also  be 
employed  in  an  emergency.  In 
hemorrhage  from  wounds  of  the 
hands  and  feet,  especially  in  chil- 

Fig.  224. 


The  Spanish  windlass. 


.Lister's  aorta  compressor. 


dren,  and  in  controlling  hemorrhage  from  wounds  of.  the 
penis,  a  piece  of  drainage-tube,  firmly  applied  above  the 
wound,  may  be  employed  with  advantage.  Care  should  be 
observed  in  applying  elastic  constriction,  for  if  the  elastic 
tube  be  applied  too  tightly,  the  subcutaneous  tissues  may  be 
divided  or  nerves  mav  be  so  compressed  that  their  func- 
tion is  destroyed.  The  tube  or  strap,  although  generally 
employed  to  control  hemorrhage  from  vessels  of  the 
extremities,  may  be  used  to  control  the  femoral  artery 
as  it  crosses  the  brim  of  the  pelvis,  by  placing  a  com- 
press over  the  artery  in  this  position,  and  then  applying 
the  elastic  band  to  secure  it  by  making  a  figure-of-eight 
turn,  passing  under  the  thigh,  crossing  over  the  pad,  and 


296 


MINOR  SURGERY. 


Fig.  225. 


then  carrying  the  ends  around  the  pelvis,  and  securing 

them. 

To   make  pressure  on  the  axillary  artery,  a  compress 

should  be  placed  in  the  axilla,  and  the  middle  of  the  tube 

placed  over  this  to  hold  it  in 
position ;  the  ends  of  the  tube  are 
then  carried  over  the  shoulder, 
where  they  are  crossed,  and 
then  carried  to  the  opposite 
axilla  and  secured. 

Fig.  226. 


Signorini's  tourniquet. 


Elastic  strap  of  Esmarch's  apparatus. 


Haemostatic  Forceps. — The  temporary  control  of  arte- 
rial hemorrhage  by  the  use  of  haemostatic  forceps  is  now 
very  generally  employed  in  surgical  operations,  and  their 
use  has  done  much  to  diminish  the  shock  following  opera- 
tions from  the  loss  of  blood.  The  haemostatic  forceps  in 
general  use  is  self-retaining  ;  it  is  clamped  upon  the  bleed- 
ing vessel,  and  is  allowed  to  remain  until  the  operation  is 
completed,  when  the  vessel  is  secured  permanently  by  the 
application  of  a  ligature,  and  the  forceps  is  removed. 
The  use  of  these  forceps  will  be  found  very  satisfactory 
in  controlling  hemorrhage  during  the  removal  of  tumors  ; 
in  amputations,  and  for  the  temporary  control  of  bleeding 
during  the  operation  of  tracheotomy,  they  will  be  found 
most  efficient,  as  also  in  abdominal  operations,  in  which 
their  utility  was  first  demonstrated  (Fig.  227). 

Esmarch's    Bandage    and    Tube. — This   apparatus, 


/>.i/. 1 ncirs  bam)A<;e  axd  tube. 


297 


which    is   applied   to  the  limbs  to    render   them    blood- 
less      during      operations, 

consists  of  a  rubber  band- 
age two  and  a  half  inches 
in  width  and  three  or  four 
yards  in  length,  and  a  rub- 
ber tube  two  yards  in  length, 
to    one    end    of    which    is 
attached  a  chain  and  to  the 
other  a  hook,  or,  better,  a 
rubber    strap,  one    inch  in 
width  and  one  and  a  half 
yards  in  length,  with  a  hook 
and  chain.     The  bandage  is 
applied  to  the  extremity  of 
the  limb,  and  is  carried  up 
the  limb  to  a  point   some 
distance     above    the    seat 
of  proposed  operation  ;  the 
bandage  is  applied  firmly, 
each  turn  overlapping  one- 
fourth  of  the  preceding  one, 
and  when  the  last  turn  has 
been  made  the  rubber  tube 
or    strap   is   wound    firmly 
around  the  limb  and  secured 
by  fastening  the  hook  into  one  of  the  links  of  the  chain 
(Tio-   228}  °  After  securing  the  tube  or  strap,  the  rubber 
bandage  is  removed  from  the  limb  ;  and  if  the  tube   has 
been   sufficiently  firmly  applied,  the  limb  will  be  found 
blanched,  and  should  be  free  from  blood  during  the  opera- 
tion.    Care  should    be   taken   not   to   apply   the  tube  or 
strap  too  tightly  upon  poorly  developed  limbs,  or  on  parts 
of  the  limb  where  large  nerve-trunks  approach  the  sur- 
face, as  thev  mav  be  subjected  to  an  amount  of  pressure 
which   will  interfere   with   their   functions   subsequently. 
I   have   knowledge   of  one  case  of  this  nature  in  which 
permanent  paralysis   of   the   limb   followed    the    use   ot 
Esrnarch's  apparatus ;  the   tube   should   be  applied   with 


Hemostatic  forceps. 


298 


MINOR  SURGERY. 


just  sufficient  firmness  to  control  the  circulation.  As  the 
strap,  when  firmly  applied,  completely  cuts  off  the  circu- 
lation of  the  parts  below,  it  should  be  applied  for  as  short 
a  time  as  possible,  as  gangrene  has  resulted  from  its  pro- 
longed use.  After  removal  of  the  tube  or  strap  there  is 
generally  free  capillary  hemorrhage,  due  to  paralysis  of 
the  vasomotor  nerves  from  pressure,  but  this  in  a  short 
time  stops.     This  appliance  is  of  the  greatest  service  in 

Fig.  228. 


Esmarch's  bandage  and  tube  applied. 

controlling  hemorrhage  at  the  time  of  operation,  and  in 
amputations  and  for  removal  of  vascular  tumors  from  the 
limbs  will  be  found  most  satisfactory.  In  operations  upon 
bones,  such  as  resection  or  sequestrotomy,  it  is  especially 
useful,  as  it  allows  the  surgeon  to  inspect  the  parts  unob- 
scured  by  hemorrhage.  I  have  found  its  use  most  satis- 
factory in  operations  for  the  removal  of  foreign  bodies,  such 
as  needles  embedded  in  extremities. 


Permanent  Control  of  Arterial  Hemorrhage. 

To  secure  this  end,  the  surgeon  may  resort  to  the  use  of 
position,  cold,  heat,  styptics,  pressure,  cauterization,  liga- 
tion, torsion,  suture  of  the  artery,  or  acupressure. 

Position. — In  arterial  hemorrhage  from  wounds  of  the 
extremities,  elevation  of  the  part  will  be  found  to  mate- 
rially diminish  the  amount  of  bleeding ;  in  hemorrhage 
from  wounds  of  the  arteries  of  the  hand,  forearm,  foot,  or 


HOT  WATER.  299 

leg,  forcible  flexion  of  the  forearm  on  the  arm  or  of  the  leg 
on  the  thigh  will  be  found  useful  in  diminishing  the  force 
of  the  blood-current. 

Cold. — The  application  of  cold  by  means  of  a  stream 
of  cold  water  or  an  ice-bag  or  pieces  of  ice  will  often  he 
found  an  efficient  means  of  controlling  hemorrhage  from 
vessels  of  small  calibre  :  it  is  especially  applicable  to  hem- 
orrhage from  wounds  of  the  vessels  of  the  mouth,  nostrils, 
vagina,  or  rectum. 

Hot  Water. — Hot  water  will  be  found  a  very  efficient 
means  of  controlling  hemorrhage  from  small  vessels,  and 
it  may  be  used  in  the  form  of  a  hot  antiseptic  solution.  It 
is  of  especial  value  in  capillary  or  parenchymatous  hem- 
orrhage, and  is  employed  in  the  form  of  a  douche  or  by 
means  of  sponges  or  gauze  pads  dipped  in  the  hot  solution 
and  packed  into  the  wound.  The  injection  of  hot  water 
is  a  most  satisfactory  method  of  controlling  uterine  hem- 
orrhage. 

Styptics. — These  agents  are  sometime-  employed  to 
control  capillary  bleeding  or  hemorrhage  from  small  ves- 
sels, and  although  their  use  is  often  satisfactory  as  regards 
the  control  of  the  bleeding,  they  have  the  disadvantage 
of  interfering  with  primary  union  in  wounds,  and  since 
the  value  of  asepsis  in  wound  treatment  has  been  demon- 
strated they  are  now  very  seldom  employed.  The  most 
valuable  styptics  are  alcohol,  alum,  oil  of  turpentine,  per- 
chloride  of  iron,  persulphate  of  iron  or  MonsePs  solution, 
acetic  acid,  vinegar,  adrenal  chloride,  antipyrin,  and  gelatin. 

Adrenalin  Chloride. — A  solution  of  adrenalin  chloride, 
1  part  to  normal  salt  solution  1000  parts,  has  been  re- 
cently employed  for  the  control  of  hemorrhage.  It  seems 
to  be  most  serviceable  in  capillary  hemorrhage. 

Antipyrin. — A  solution  of  antipyrin,  5  per  cent.,  in 
sterilized  water  possesses  marked  styptic  action.  As  it 
also  possesses  antiseptic  properties  and  is  not  toxic,  it  may 
be  used  to  control  capillary  bleeding  from  the  surface  of 
the  brain,  the  intestines  and  peritoneum,  and  from  bone- 
cavities. 

Gelatin. — This  may  be  used  as  a  styptic  where  it  can 


300  MINOR  SURGERY. 

be  applied  locally  in  a  5  to  10  per  cent,  solution  in  normal 
salt  solution.  It  may  be  applied  by  injecting,  irrigating, 
or  tamponing  the  bleeding  area.  It  has  been  employed 
successfully  in  epistaxis,  hsematemesis,  vesical  and  uterine 
hemorrhage,  and  in  superficial  wounds  in  patients  the 
subjects  of  haemophilia. 

Pressure. — For  the  permanent  control  of  arterial  hem- 
orrhage, pressure  may  be  applied  directly  to  the  bleeding 
point  or  surface  by  means  of  a  compress  of  antiseptic  gauze 
or  by  strips  of  gauze  packed  firmly  into  the  cavity  from 
whose  surface  the  bleeding  arises. 

Compresses  are  used  with  the  best  results  where  the 
proximity  of  a  bone  gives  a  firm  substance  upon  which 
the  vessel  may  be  compressed,  as  is  the  case  in  the  vessels 
of  the  scalp.  Pressure  applied  by  means  of  packing  with 
strips  of  gauze  will  be  found  most  efficient  in  controlling 
hemorrhage  from  cavities,  such  as  the  nose,  vagina,  or 
rectum,  and  in  the  cavities  resulting  from  the  removal  of 
necrosed  or  carious  bone.  Pressure  may  be  indirectly 
applied  to  an  artery  by  flexing  the  joint  over  a  compress 
or  by  firm  bandaging  of  the  limb. 

In  controlling  bleeding  from  a  divided  artery  in  a  bony 
cavity,  such  as  the  inferior  dental,  a  piece  of  catgut  liga- 
ture may  be  forced  into  the  canal,  and  will  control  the 
bleeding  in  a  most  satisfactory  manner,  or  it  may  be 
controlled  by  forcing  a  small  piece  of  Hor sky's  wax  into 
the  opening  in  the  bone ;  this  wax  is  composed  of  wax,  7 
parts ;  oil,  2  parts ;  and  carbolic  acid,  1  part. 

Halsted  has  introduced  a  material  known  as  gut  wool, 
which  is  prepared  from  the  same  material  from  which  cat- 
gut is  made.  This  is  cut  into  fine  shreds,  and  is  used  to 
control  hemorrhage  from  bone,  being  pressed  into  the  open- 
ing or  cavity  in  the  bone  from  which  the  bleeding  arises. 

The  troublesome  hemorrhage  sometimes  occurring  after 
the  removal  of  a  tooth  may  be  controlled  by  packing  the 
alveolar  cavity  with  a  strip  of  iodoform  gauze,  or  by 
introducing  a  wedge-shaped  piece  of  cork  and  holding 
it  in  place  by  fastening  the  jaws  together  by  means  of 
a  bandage. 


TORSION.  301 

Cauterization. — The  use  of  cauterization  by  means  of  a 
hot  iron  is  a  satisfactory  method  of  arresting  hemorrhage. 
Care  should  be  taken  to  have  the  iron  only  of  a  dull-red 
or  black  heat,  as  the  result  desired  is  not  the  destruction 
of  the  tissues,  but  the  coagulating  effect  of  heat  upon  them. 
The  form  of  cautery-iron  employed  will  depend  upon  the 
size  and  position  of  the  vessel.  Paquelin's  cautery  is  also 
a  satisfactory  apparatus  to  use  for  the  control  of  hemor- 
rhage. 

The  control  of  arterial  bleeding  by  cauterization  is  often 
resorted  to  in  operations  upon  the  jaws  and  in  the  removal 
of  tumors  from  the  mouth  or  pharynx  or  of  the  tonsils ; 
it  is  also  frequently  employed  to  control  hemorrhage  in 
operations  upon  the  uterus  and  the  rectum,  and  also  that 
resulting  from  the  removal  of  abdominal  tumors,  where 
the  application  of  a  ligature  is  difficult  and  often  impos- 
sible. 

Torsion. — This  method  of  controlling  arterial  hemor- 
rhage consists  in  seizing  the  end  of  the  artery,  drawing  it 
slightly  out  of  its  sheath  and  twisting  it ;  it  may  be  accom- 
plished with  a  single  pair  of  forceps  or  haemostatic  forceps, 
or  by  two  pairs  of  forceps.  In  the  latter  method  the 
vessel  is  held  by  one  pair  of  forceps  and  is  twisted  by  the 
second  pair. 

Torsion  of  arteries  in  accidental  wounds  is  quite  com- 
mon, and  in  many  cases  controls  the  hemorrhage  until  sur- 
gical aid  is  rendered.  I  have  seen  hemorrhage  from  the 
femoral  artery  in  Scarpa's  triangle  completely  controlled 
in  this  manner  in  a  case  of  avulsion  of  the  thigh  from  a 
railway  injury. 

Fig.  229. 


Double-spring  artery  forceps. 


In  vessels  of  moderate  size  it  may  be  practised  with  one 
pair  of  forceps,  and  the  ordinary  double-spring  artery  for- 
ceps (Fig.  229)  or  haemostatic  forceps  will  be  found  satis- 


302 


MINOR  SURGERY. 


factory  for  such  cases.  In  larger  arteries  two  forceps  should 
be  employed,  or  some  of  the  numerous  forms  of  torsion 
forceps  which  have  been  devised  for  this  purpose. 

Ligation. — The  use  of  the  ligature  is  by  far  the  most 
generally  employed  method  of  controlling  arterial  hemor- 
rhage. The  materials  used  are  silk,  hemp  thread,  or  cat- 
gut.    Catgut  or  silk  is  the  material  generally  employed. 

Fig.  230. 


Tenaculum. 

The  vessel  is  seized  with  a  pair  of  artery  or  haemostatic 
forceps  or  a  tenaculum  (Fig.  230)  and  drawn  out  of  its 
sheath,  and  a  ligature  of  sterilized  catgut  or  silk  is  thrown 
around  it  and  secured  by  a  surgeon's  knot,  or  by  a  reef 
knot  and  a  surgeon's  knot  combined,  and  when  firmly 
tied  the  ends  of  the  ligature  are  cut  short  in  the  wound. 

Fig.  231. 


Aneurism  needle  armed  with  ligature. 

When  ligatures  are  applied  to  vessels  in  their  continuity, 
they  may  be  threaded  into  an  eyed  probe  or  aneurism  needle 
(Fig.  231)  and  carried  around  the  vessel  and  secured. 

Deep  Sutures. — A  convenient  method  of  applying  a 
ligature  to  a  bleeding  point  in  a  deep  wound,  or  to  a  vessel 
in  tissues  which  are  of  such  a  nature  as  not  to  permit  of 
the  isolation  of  the  vessel,  is  to  use  a  curved  needle 
threaded  with  a  catgut  ligature,  which  is  passed  deeply 


SUTURE  OF  ARTERIES.  303 

into  the  tissues  near  the  vessel  and  brought  out  on  the 
opposite  side;  the  ligature  thus  placed  is  then  firmly  tied, 
and  the  ends  are  cut  short  in  the  wound  (Fig.  232). 

Fig.  232. 


Artery  occluded  by  suture.    (Esmarch.) 

Suture  of  Arteries. — Wounds  of  arteries,  both  longi- 
tudinal and  transverse,  have  been  successfully  closed  by 
sutures  both  in  man  and  the  lower  animals.  It  is  recom- 
mended in  the  larger  arteries,  where  more  than  two-thirds 
of  the  circumference  has  been  divided,  to  resect  the  injured 
portion  of  the  vessel,  where  it  can  be  done  without  remov- 
ing more  than  three-fourths  of  an  inch  of  the  vessel,  and 
invaginate  one  end  into  the  other,  and  to  secure  their  fixa- 
tion by  fine  silk  sutures.  In  longitudinal  wounds  the 
edges  may  be  brought  together  by  fine  silk  sutures,  intro- 
duced by  means  of  a  fine  cambric  needle.  The  sutures 
should  be  inserted  from  one-sixteenth  to  one-twentieth  of 
an  inch  apart,  and  one-sixteenth  of  an  inch  from  the  edges 
of  the  wound,  and  should  include  only  the  adventitia  and 
media,  not  perforating  the  intima.  During  the  operation 
the  circulation  in  the  vessel  should  be  controlled  both 
above  and  below  the  wound  by  forceps  covered  with 
rubber  tubing.  Where  a  distinct  sheath  is  present,  it 
should  be  sutured  over  the  wound ;  and  if  this  is  not 
present,  muscle  or  fascia  should  be  sutured  over  the  closed 
wound  in  the  vessel. 

Acupressure. — In  this  method  of  controlling  arterial 
hemorrhage   a   needle    or    pin    is    used,  which    is   thrust 


304 


MINOR  SURGERY. 


through  the  tissues  in  such  a  way  as  to  compress  the  artery. 
Jn  the  first  method  of  acupressure  the  surgeon  places  a 
finger  of  his  left  hand  upon  the  mouth  of  the  bleeding 
vessel,  and  with  his  right  hand  introduces  the  needle  from 
the  cutaneous  surface  and  passes  it  through  the  thickness 
of  the  flap  until  its  point  projects  for  a  couple  of  lines  or 
so  from  the  surface  of  the  wound  a  little  to  the  right  side 
of  the  end  of  the  vessel.  By  forcibly  inclining  the  head 
of  the  needle  toward  his  right,  he  brings  the  projecting 
portion  of  its  point  firmly  down  on  the  side  of  the  vessel, 
and  after  seeing  that  it  occludes  the  artery  he  makes  it 
re-enter  the  flesh  as  near  as  possible  to  the  left  side  of  the 
wound  and  pushes  the  needle  through  the  flesh  until  its 


Fig.  233. 


Fig.  234. 


Acupressure — first  method  ;  raw 
surface.    (Erichsen.) 


Acupressure— first  method  ;  cutaneous 
surface.    (Erichsen.) 


point  comes  out  again  at  the  cutaneous  surface  (Figs.  233 
and  234). 

There  are  a  number  of  methods  of  using  the  needle  or 
pin  in  acupressure  to  produce  occlusion  of  the  vessel,  but 
as  this  method  of  arresting  hemorrhage  is  not  often  em- 
ployed at  the  present  time  they  need  not  be  described. 

Rules  for  Ligating  Wounded  Arteries.— The  follow- 
ing rules  for  the  application  of  ligatures  to  wounded 
arteries  have  been  recommended  by  Ashhurst : 

1.  In  cases  of  primary  hemorrhage,  no  operation  should 
be  performed  upon  an  artery  unless  it  is  at  the  moment 
actually  bleeding.  The  exception  to  this  rule  is  in  the 
cases  where  the  vessel  is  seen  to  pulsate  in  the  wound,  or 
where  the  wound  involves  the  region  of  a  large  artery  and 


VENOUS  HEMORRHAGE.  305 

the  patient  has  to  be  transported  or  may  be  in  a  position 
not  to  receive  surgical  aid  subsequently  if  needed ;  under 
these  circumstances,  the  vessel  should  be  tied  or  the 
wound  should  be  explored  to  ascertain  the  fact  that  no 
important  vessel  has  been  injured. 

'2.  In  applying  a  ligature  to  a  wounded  artery,  the 
surgeon  should  cut  down  directly  upon  it  at  the  point  from 
which  it  bleeds  and  secure  it  in  the  wound.  This  rule 
holds  good  for  both  primary  and  secondary  hemorrhage. 

3.  Two  ligatures  should  be  applied,  one  to  each  end  of 
the  artery  if  it  be  completely  divided,  and  one  on  each 
side  of  the  wound  if  the  latter  has  not  severed  all  the  coats 
of  the  artery.  This  procedure  is  adopted  for  the  reason 
that  arterial  anastomosis  is  so  free  that  the  proximal  liga- 
ture will  not  always,  even  temporarily,  arrest  the  bleeding  ; 
and  if  it  does  accomplish  this  object  at  the  time,  after  the 
collateral  circulation  is  established  bleeding  is  apt  to  occur 
from  the  distal  extremity  of  the  divided  vessel.  If  the 
coats  of  the  artery  are  not  completely  severed,  their  divis- 
ion should  be  completed,  either  before  or  after  the  appli- 
cation of  the  proximal  and  distal  ligatures,  thereby  favor- 
ing contraction  and  retraction  of  the  ends  of  the  divided 
vessel. 

Treatment  of  Venous  Hemorrhage. 

Bleeding  from  small  veins  often  stops  spontaneously 
unless  there  is  pressure  upon  the  wounded  veins  on  the 
cardiac  side  of  the  wound.  It  is,  however,  very  satisfac- 
torily controlled  by  position  or  by  the  application  of  a 
compress  and  bandage,  or  by  the  use  of  a  ligature ;  if 
the  divided  vein  be  a  large  one,  it  is  well  to  secure  both 
ends  by  ligatures.  The  free  bleeding  arising  from  rupt- 
ured varicose  veins  of  the  leg  is  easily  controlled  by  the 
application  of  a  compress  and  bandage;  while  hemorrhage 
from  the  larger  veins,  such  as  the  jugular,  should  be  con- 
trolled by  the  application  of  ligatures,  as  in  the  case  of 
wounded  arteries. 

The  Lateral  Ligature. — The  application  of  the  lateral 
ligature   to   small   wounds   of  large   veins,  such   as   the 

20 


Q 


06  MINOR  SURGERY. 


femoral,  or  to  wounds  of  venous  sinuses,  has  been 
recommended  and  employed  with  good  results:  this  pro- 
cedure consists  in  pinching  up  the  wall  of  the  vein  so  as 
to  include  the  orifice  of  the  wound  and  throwing  a  deli- 
cate ligature  around  it. 

Suture  of  Veins. — This  procedure  has  also  been  em- 
ployed with  success  in  the  case  of  the  larger  veins.  The 
bleeding  should  be  controlled  by  pressure  upon  the  vein 
on  both  sides  of  the  wound,  and  the  wound  in  the 
vessel  should  be  closed  by  fine  silk  sutures  applied  closely 
together  by  means  of  a  fine  cambric  needle.  The  employ- 
ment of  sutures  and  lateral  ligatures  in  wounds  of  veins 
possesses  the  advantage  of  controlling  the  bleeding  and  at 
the  same  time  not  causing  obliteration  of  the  vessel  at  the 
seat  of  injury. 

The  actual  cautery  may  also  be  employed  for  the  con- 
trol of  venous  hemorrhage  in  situations  in  which  its  arrest 
by  pressure  or  the  ligature  is  not  feasible. 

Compression  by  means  of  strips  of  sterilized  gauze  is 
often  employed  to  control  venous  hemorrhage  from  cavi- 
ties. 

Treatment  of  Capillary  Hemorrhage. 

Capillary  or  parenchymatous  hemorrhage  is  often 
arrested  spontaneously  on  exposure  of  the  surface  of  the 
wound  to  the  air,  but  the  bleeding  may  not  be  controlled 
and  may  be  so  profuse  that  its  arrest  becomes  a  matter 
of  importance.  To  control  this  form  of  bleeding,  pres- 
sure may  be  applied  to  the  bleeding  surface  for  a  short 
time,  and  if  this  fails  to  arrest  it,  sponging  the  surface 
with  dilute  alcohol  will  sometimes  prove  satisfactory;  but 
the  best  application  to  arrest  hemorrhage  of  this  nature 
is  hot  water,  which  may  be  used  in  the  form  of  a  hot 
bichloride  solution  or  antipyrin  solution. 

Adrenal  chloride,  1  part  to  normal  salt  solution  1000 
parts,  or  a  5  to  10  per  cent,  solution  of  gelatin  in  normal 
salt  solution,  may  be  employed. 

Acetic  acid  and  vinegar  are  also  sometimes  employed 
for  the  same  purpose.     In  cases  where  the  means  men- 


EPISTAXIS.  307 

tionecl  above  fail  to  control  the  bleeding,  it  may  he  neces- 
sary to  pack  the  wound  with  strips  of  antiseptic  gauze ; 
this  dressing  is  most  serviceable  when  the  hemorrhage 
comes  from  cavities  such  as  result  from  the  removal  of 
tumors  or  excisions  of  joints,  and  for  the  control  of  bleed- 
ing following  the  removal  of  necrosed  or  carious  bone. 
To  control  hemorrhage  from  mucous  cavities,  such  as  the 
nose,  rectum,  and  vagina,  this  method  of  treatment  is  also 
frequently  resorted  to. 

Treatment  of  Secondary  Hemorrhage. 

Secondary  hemorrhage  following  the  use  of  the  ligature 
or  other  means  of  controlling  bleeding,  usually  results 
from  a  septic  condition  of  the  wound,  and  is  due  to  a  septic 
arteritis.  Since  the  adoption  of  the  antiseptic  and  aseptic 
methods  of  wound  treatment  it  is  a  much  less  frequent 
complication  of  wounds. 

The  treatment  of  this  complication  is  both  constitu- 
tional and  local.  The  constitutional  treatment  consists  in 
the  use  of  those  remedies  which  were  mentioned  as  ser- 
viceable in  primary  hemorrhage,  and  the  drugs  upon 
which  most  reliance  should  be  placed  are  opium  and  ergot. 

The  local  treatment  of  this  form  of  hemorrhage  consists 
in  the  use  of  the  various  means  of  controlling  hemorrhage 
which  have  been  mentioned,  such  as  the  ligature,  hot  water, 
pressure,  or  the  actual  cautery.  If  possible,  it  is  well  to 
secure  the  vessel  from  which  the  bleeding  arises  in  the 
wound ;  if  for  any  reason  this  cannot  be  done,  the  main 
artery  should  be  ligated  above  the  wound  if  the  hemor- 
rhage be  arterial. 

Control  of  Hemorrhage  from  Special  Parts. 

Epistaxis,  or  hemorrhage  from  the  nose,  may  be  so  pro- 
fuse as  to  require  surgical  interference.  To  control  this 
form  of  hemorrhage,  the  application  of  iced  compresses  to 
the  surface  of  the  nose  may  first  be  made  use  of;  and  if 
this  fails  to  control  the  bleeding,  the  surgeon  or  the  patient 


308  MINOR  SURGERY. 

should  grasp  the  cartilaginous  portion  of  the  nose  with  his 
thumb  and  forefinger  in  such  a  manner  as  to  keep  the  nos- 
trils tightly  closed,  which  will  prevent  the  passage  of  air 
through  the  nose  and  thus  permit  clots  to  form,  arresting 
the  flow  of  blood.  Bleeding  from  the  nose  often  arises 
from  the  erosion  of  a  small  artery  low  down  upon  the  sep- 
tum, which  can  be  freely  exposed  by  introducing  a  nasal 
speculum,  and  the  bleeding  point  may  be  touched  with  a 
cautery-iron,  thus  avoiding  the  necessity  of  plugging  the 
nares.'  If  these  simple  means  fail  to  arrest  the  bleeding, 
the  nasal  cavity  or  cavities  may  be  packed  with  strips  of 
antiseptic  gauze  introduced  into  the  anterior  nares,  and 
pushed  backward  by  a  director  or  probe ;  this  will  often 
be  found  a  satisfactory  means  of  arresting  the  bleeding. 
This  method  may  be  supplemented  by  a  plug  of  antiseptic 
cotton  introduced  into  the  posterior  nares  with  the  finger. 
The  use  of  a  rubber  tampon,  consisting  of  a  rubber  bag, 
introduced  into  the  nares  in  a  collapsed  state  and  after- 
ward inflated,  has  also  been  recommended  for  the  control 
of  this  variety  of  hemorrhage. 

Another  method  of  controlling  hemorrhage  from  the 
nose  consists  in  introducing  a  small  piece  of  sponge  or 
pledget  of  sterilized  gauze,  tied  to  a  strong  silk  ligature, 
into  the  anterior  nares  and  pushing  it  back  along  the  floor 
of  the  nose  to  the  posterior  nares ;  a  piece  of  sponge 
or  gauze  about  the  size  of  a  marble,  with  a  hole  in  the 
centre,  is  threaded  on  the  ligature  and  pushed  back  until 
it  comes  in  contact  with  the  first  piece  introduced,  and  thus 
by  introducing  a  number  of  pieces  of  sponge  or  gauze  in 
this  way  the  nasal  cavity  may  be  completely  filled  and 
the  bleeding  arrested.  Care  should  be  taken  to  see  that 
the  sponge  has  been  rendered  aseptic  before  being  intro- 
duced, and  the  nasal  cavity  should  be  washed  out  with  an 
antiseptic  solution  before  its  introduction.  The  sponges 
or  gauze  may  be  allowed  to  remain  for  twenty-four  to 
forty-eight  hours  (Fig.  235). 

Plugging  the  nares  by  means  of  Bellocq's  canula  is  also 
employed  to  arrest  hemorrhage  from  the  nasal  cavities ; 
the  canula,  armed  with  a  strong  ligature,  is  passed  along 


KPISTAXIS. 
Fig.  235. 


309 


Plugging  the  nares  from  the  front.    (Roberts.) 
Fig.  236. 


Plugging  the  nares  with  Bellocq's  eanula.    (Fergusson.) 


310  MINOR  SURGERY. 

the  floor  of  the  nose  until  it  reaches  the  pharynx,  when 
the  spring  being  protruded,  the  ligature  is  seized  and 
brought  out  of  the  mouth  and  secured  to  a  plug  of  lint  or 
of  antiseptic  gauze  of  the  required  size,  and  upon  with- 
drawing the  instrument  the  plug  is  brought  into  position 
in  the  posterior  nares  and  the  end  of  the  ligature  allowed 
to  protrude  from  the  mouth  to  facilitate  its  removal  (Fig. 
236).  An  ordinary  flexible  catheter  may  be  employed  in- 
stead of  Bellocq's  canula  for  the  introduction  of  the  liga- 
ture. 

Hemorrhage  from  the  Urethra. — In  hemorrhage  from 
the  urethra,  if  profuse,  the  blood  will  trickle  from  the 
meatus  ;  or  if  efforts  at  micturition  are  made,  the  first  por- 
tion of  urine  will  contain  blood,  but  afterward  will  be  clear, 
and  the  last  portion  will  contain  a  few  drops  of  pure  blood. 

This  variety  of  bleeding,  if  it  proceeds  from  the  ante- 
rior portion  of  the  urethra,  may  be  controlled  by  the 
introduction  of  a  catheter  and  the  application  of  a  band- 
age around  the  penis  applied  so  as  to  make  only  moderate 
pressure. 

If  the  bleeding  comes  from  the  posterior  portion  of  the 
urethra,  it  will  often  be  controlled  by  the  application  of 
cold  or  pressure  to  the  perineum,  or  by  the  introduction 
of  a  cold  steel  bougie,  or  by  the  injection  of  a  weak  solu- 
tion of  tannic  acid  or  antipyrin. 

Hemorrhage  from  the  Bladder. — In  this  variety  of 
hemorrhage  the  first  portion  of  the  urine  may  be  blood- 
stained, and  the  last  portion  will  contain  more  blood  and 
clots  as  the  organ  contracts,  which  distinguishes  it  from 
hemorrhage  from  the  kidneys,  in  which  admixture  of  blood 
with  the  urine  renders  it  of  a  smoky  color,  or  dark  red  if 
the  bleeding  is  profuse. 

To  control  bleeding  from  the  bladder,  a  catheter  should 
be  introduced  and  the  urine  and  clots  withdrawn  ;  the 
bladder  should  next  be  washed  out  with  a  warm  or  cold 
boric  acid  solution.  In  severe  cases  a  weak  solution  of 
tannic  acid,  antipyrin,  alum,  or  adrenal  solution  may  be 
employed.  The  application  of  ice  to  the  perineum  and 
suprapubic  regions  may  also  be  employed  with  advantage. 


TREATMENT  OF  ABS(  ESS  311 

Hemorrhage  from  the  Rectum.— This  variety  of 
bleeding  may  be  controlled  by  the  injection  of  cold  or 
astringent  enemata.  If  the  bleeding  be  profuse,  a  speculum 
should  be  introduced,  and  when  the  source  of  the  bleed- 
ing has  been  discovered  the  actual  cautery  or  a  ligature 
should  be  applied.  If  this  is  not  feasible,  the  rectum  may 
be  plugged  with  strips  of  antiseptic  gauze,  or  a  piece  of 
a  rubber  catheter  of  large  calibre  may  be  wrapped  with 
gauze  and  introduced  into  the  rectum,  the  end  of  the 
catheter  being  allowed  to  protrude  ;  by  using  this  tube 
flatus  can  escape,  and  if  the  bleeding  is  not  controlled 
blood  will  escape  through  the  tube,  preventing  the  risk 
of  concealed  hemorrhage.  If  the  bleeding  arises  from 
hemorrhoids  or  polypus  of  the  rectum,  operative  treatment 
of  these  conditions  should  be  undertaken  to  remove  the 
cause  of  bleeding. 

TREATMENT  OF  ABSCESS. 

In  operations  for  evacuation  of  the  contents  of  abscesses 
care  should  be  taken  to  observe  every  precaution  to  pre- 
vent a  new  infection  of  the  wound  or  abscess  cavity  ;  the 
skin  over  the  abscess  should  be  carefully  cleaned  to  make 
it  aseptic,  the  hands  of  the  surgeon  and  the  instruments  to 
be  brought  in  contact  with  it  should  also  be  aseptic. 
These  precautions  should  be  especially  observed  in  the 
opening  of  chronic  abscesses  when  a  new  variety  of  infec- 
tion is  liable  to  be  introduced  if  aseptic  precautions  are  not 
rigidly  observed. 

Acute  Abscess. — This  variety  of  abscess  should  be 
opened  by  incision,  and  this  is  best  done  with  a  straight, 
narrow,  sharp-pointed  bistoury.  The  incision  should  be 
deep  enough  to  expose  freely  the  cavity  of  the  abscess, 
and  should  be  parallel  with  and  not  across  important 
structures,  and  it  should  also  be  made  at  as  dependent  a 
portion  as  possible.  Abscesses  of  the  limbs  are  opened  by 
a  longitudinal  incision,  and  those  in  the  region  of  the  anus 
and  breast  by  an  incision  radiating  from  the  anus  or  nipple. 

Hilton's  Method.— In  deep-seated  abscesses  in  the  region 


31^  MINOR  SURGERY. 

of  important  structures  the  method  of  opening  suggested 
by  Mr.  Hilton  may  be  employed  with  advantage:  it  con- 
sists in  making  a  small  incision  through  the  skin  and 
cellular  tissue;  a  director  is  next  pushed  through  the  tis- 
sues into  the  abscess  cavity,  which  will  be  shown  to  have 
been  reached  by  the  escape  of  pus  along  the  director;  a 
dressing-forceps  with  the  blades  closed  is  now  pushed 
along  the  director  into  the  abscess  cavity,  and  when  this 
has  been  accomplished  the  director  is  withdrawn  and  the 
forceps  removed  with  the  blades  expanded  so  as  to 
dilate  the  wound  and  allow  the  pus  to  escape.  Pressure 
should  not  be  made  upon  the  walls  of  the  abscess  to  empty 
it,  as  by  so  doing  delicate  vessels  may  be  ruptured  and 
cause  hemorrhage,  and  the  spread  of  the  infection  may 
be  facilitated. 

The  cavity  of  the  abscess  having  been  emptied  of  pus, 
it  may  be  irrigated  with  a  stream  of  carbolic  or  bichlo- 
ride solution,  or  the  irrigation  of  the  cavity  may  be 
omitted,  and  if  the  cavity  is  not  very  large  or  deep,  no 
drainage-tube  need  be  introduced,  and  a  small  piece  of 
protective  may  be  placed  between  the  lips  of  the  wound 
to  prevent  their  adhesion ;  but  if,  on  the  other  hand,  the 
cavity  is  extensive  and  deeply  situated,  a  rubber  drainage- 
tube  or  a  strip  of  iodoform  gauze  should  be  introduced  to 
the  bottom  of  the  cavity  to  secure  free  drainage,  and  if  a 
tube  be  used,  fixed  at  the  surface  of  the  skin  by  a  safety- 
pin.  A  gauze  dressing,  consisting  of  a  number  of  layers, 
which  has  been  moistened  in  carbolic  or  bichloride  solu- 
tion, is  next  placed  over  the  wound,  and  is  covered  by  a 
number  of  layers  of  dry  gauze,  which  are  in  turn  covered 
by  a  piece  of  rubber-tissue.  The  latter  may  be  substi- 
tuted by  a  few  layers  of  bichloride  cotton,  and  the  dressing 
is  finally  secured  by  a  roller-bandage.  The  dressing  is 
removed  at  the  end  of  two  or  three  days,  the  cavity  being 
washed  out  with  one  of  the  antiseptic  solutions  previously 
mentioned.  The  drainage-tube  may  then  be  shortened  or 
removed,  and  the  dressings  reapplied  as  at  the  primary 
dressing.  Under  this  method  of  treatment  acute  abscesses 
usually  heal  promptly. 


TREATMENT  OF  ABSCESS.  313 

Chronic  or  Tuberculous  Abscess. — This  variety  of 
abscess,  which  occurs  chiefly  in  connection  with  diseases 
of  the  bones  or  joints  or  of  the  lymphatic  system,  is 
tubercular  in  origin,  and  may  be  opened  in  various  ways, 
the  time  at  which  this  should  be  done  depending  upon 
the  size  and  situation  of  the  abscess  and  the  amount  of 
constitutional  and  local  disturbance  which  the  patient  ex- 
periences from  its  presence. 

Aspiration. — A  tuberculous  abscess  may  be  evacuated  by 
means  of  the  aspirator  ;  the  pus  being  withdrawn  as  far  as 
possible,  the  puncture  is  sealed  with  a  small  piece  of  gauze 
covered  with  iodoform  collodion.  Reaccumulation  of  pus 
often  takes  place,  and  the  aspiration  has  to  be  repeated 
a  number  of  times.  The  greatest  difficulty  in  the  success- 
ful removal  of  the  contents  of  tuberculous  abscesses  by 
means  of  aspiration  is  the  presence  of  cheesy  masses  in  the 
pus,  which  occlude  the  canula  and  often  prevent  complete 
emptying  of  the  cavity. 

Puncture  and  Injection. — This  variety  of  abscess  may 
also  be  evacuated  by  making  a  puncture  through  the  skin 
and  overlying  tissues  with  a  narrow  bistoury,  the  surface 
having  been  previously  thoroughly  washed  with  soap  and 
water  and  with  a  carbolic  or  bichloride  solution  ;  a  direc- 
tor is  next  pushed  through  this  small  wound  into  the 
cavity  of  the  abscess,  and  the  pus  is  allowed  to  escape  by 
stretching  the  wound  with  the  director ;  when  the  cavity  is 
emptied  of  pus  it  is  washed  out  with  a  carbolic  or  bichlo- 
ride solution  introduced  into  it  by  pushing  the  nozzle  of  a 
syringe  into  the  cavity,  and  this  is  allowed  to  escape  in  the 
same  way  as  the  pus  previously  did.  When  all  the  irri- 
gating solution  has  escaped,  the  cavity  may  be  injected 
with  an  emulsion  composed  of  iodoform,  1  part,  glycerin  10 
parts ;  after  this  has  been  introduced  the  small  wound  is 
closed  by  a  compress  of  antiseptic  gauze  held  in  place  by 
a  compress  of  bichloride  cotton  and  a  bandage  or  by  strips 
of  adhesive  plaster.  The  injection  of  the  iodoform  emul- 
sion need  not  be  repeated  as  long  as  iodoform  continues  to 
be  excreted  in  the  urine. 

In  evacuating  tuberculous  abscesses  by  means  of  the  as- 


314  MINOR  SURGERY. 

pirator  or  by  a  small  puncture,  there  is  absence  of  shock, 
and  the  loss  of  blood  is  insignificant,  so  that  these  pro- 
cedures should  generally  be  first  employed,  and  the  more 
radical  operation  of  incision  and  curetting  of  the  cavity 
of  the  abscess,  which  is  accompanied  with  a  certain  amount 
of  shock  and  hemorrhage,  should  be  reserved  for  those 
cases  in  which  the  less  severe  operations  have  not  been 
followed  by  a  satisfactory  result. 

Incision. — Tuberculous  abscesses  are  also  treated  by 
making  a  free  incision  into  the  abscess  cavity  with  full 
antiseptic  precautions,  and  after  the  escape  of  the  puru- 
lent matter  the  walls  of  the  abscess  should  be  thoroughly 
scraped  with  a  curette ;  after  the  cavity  has  been  freely 
washed  out  with  a  carbolic  or  bichloride  solution  large 
drainage-tubes  are  introduced  and  an  antiseptic  dressing 
is  applied  to  the  wound.  The  edges  of  the  incision  may 
be  brought  together  by  sutures  without  the  introduction 
of  drainage,  or  the  cavity  may  be  packed  with  iodoform 
gauze  and  allowed  to  heal  by  granulation.  The  dressings 
are  removed  as  soon  as  they  become  soaked,  and  the  drain- 
age-tubes are  shortened  or  removed  as  the  discharge  dimin- 
ishes and  the  cavity  contracts. 

Diffused  Suppuration. — This  form  of  suppuration  is 
treated  by  numerous  punctures  or  incisions,  which  allow 
the  purulent  matter  to  escape  ;  and  where  sloughs  are  pres- 
ent, free  incisions  may  be  required  to  give  exit  to  the 
necrosed  tissues ;  the  introduction  of  drainage-tubes  may 
also  be  required.  The  wounds  and  the  cavities,  as  far  as 
possible,  should  be  washed  out  with  a  carbolic  or  bichlo- 
ride solution  and  an  antiseptic  gauze  dressing  applied. 

Sinuses. — These  are  suppurating  tracts  which  result 
from  abscesses  or  wounds.  If  superficial,  they  should  be 
laid  open  freely  and  their  surfaces  scraped  with  a  curette, 
and  then  lightly  packed  with  strips  of  bichloride  or  iodo- 
form gauze  and  covered  by  an  antiseptic  dressing.  If 
they  are  too  deep  to  be  treated  by  incision,  their  healing 
may  be  facilitated  by  the  injection  of  stimulating  solu- 
tions introduced  by  means  of  a  syringe ;  the  employment 
of  solutions  of  chloride  of  zinc,  nitrate  of  silver,  and  sul- 


SHOCK.  315 


phate  of  copper,  varying  in  strength  from  5  to  20  grains 
to  the  ounce  of  water,  will  often  prove  satisfactory. 


SHOCK. 

Shock  is  a  condition  of  physical  depression  or  prostra- 
tion which  often  develops  after  severe  injuries  or  opera- 
tions. Paralysis  of  the  vascular  tone  in  the  arteries,  with 
coincident  feebleness  of  the  action  of  the  heart,  causes  an 
unequal  distribution  of  the  blood,  and  the  balance  of  the 
circulation  is  disturbed  ;  the  abdominal  veins  become  dis- 
tended and  the  right  side  of  the  heart  becomes  engorged, 
the  amount  of  blood  in  the  arteries  being  correspondingly 
lessened  ;  the  brain  and  the  lungs  become  anaemic,  and  if 
the  condition  persists  the  action  of  the  heart  is  arrested. 
The  essential  condition  of  shock  is  inhibition  of  nerve 
force  and  reflex  paralysis.  Shock  may  develop  immedi- 
ately upon  or  some  time  after  the  reception  of  the  injury. 
Every  traumatism  is  probably  followed  by  a  certain  amount 
of  shock,  and,  as  a  rule,  its  degree  is  proportionate  to 
the  severity  of  the  injury  received.  Yet  this  rule  is 
not  without  exception  ;  certain  classes  of  injuries  are  at- 
tended with  marked  shock,  and  the  part  of  the  body  sus- 
taining the  injury  will  have  an  important  influence  upon 
the  degree  of  development  of  shock.  Contusions  of  the 
viscera,  wounds  of  the  testicle,  contused  and  lacerated 
wounds  of  the  trunk  and  extremities,  if  extensive  and  ac- 
companied by  free  hemorrhage,  are  usually  followed  by 
marked  and  often  fatal  shock.  Gunshot  wounds  causing 
perforation  of  important  cavities  of  the  body,  injuries  of 
the  viscera,  and  shattering  of  the  bones  are  also  well  recog- 
nized as  giving  rise  to  shock  in  a  marked  degree.  Burns 
and  scalds,  if  they  involve  a  considerable  surface  of  the 
body,  are  attended  with  severe  shock. 

Diagnosis. — The  condition  of  shock  resulting  from 
purely  emotional  causes  is  usually  not  profound  or  pro- 
longed, and  can  be  differentiated  from  that  resulting  from 
corporeal  injuries  by  the  history  of  the  case.     The  con- 


316  MINOR  SURGERY. 

dition  arising  from  excessive  hemorrhage  presents  many 
symptoms  common  to  shock,  but  here  the  nature  of  the 
injury  will  often  assist  in  the  diagnosis,  and  in  doubtful 
cases  examination  of  the  blood  may  be  of  service,  for  if 
such  an  examination  shows  that  the  red  blood-cells  are 
considerably  diminished,  being  3,500,000  or  less,  it  is 
probable  that  the  condition  is  due  to  hemorrhage  rather 
than  shock.  Fat  embolism  may  also  be  confounded  with 
shock,  but  it  should  be  remembered  in  differentiating  the 
conditions  that  shock  usually  appears  promptly,  and  the 
symptoms  of  fat  embolism  from  thirty-six  hours  to  three 
days  after  the  injury.  The  experimental  researches  of 
Crile  have  largely  confirmed  our  clinical  observations  as 
regards  the  development  of  shock  in  injuries  and  opera- 
tions in  different  regions  of  the  body. 

A  patient  suffering  from  shock  presents  pallor  of  the 
surface,  paleness  of  the  lips,  dilated  pupils,  clammy  moist- 
ure of  the  skin,  muscular  debility,  occasionally  relaxation 
of  the  sphincters,  frequent,  feeble,  irregular  pulse,  subnor- 
mal temperature,  and  feeble,  short,  sighing  respiration ;  in 
many  cases  extreme  thirst  is  a  prominent  symptom.  The 
senses  are  often  perfectly  retained.  The  temperature  is 
always  subnormal,  and  may  vary  from  a  point  a  little 
below  the  normal  to  a  point  below  90°  F.  (32°  C).  A 
depression  below  97°  F.  (36°  C),  if  it  persists  for  a  few 
hours,  usually  indicates  a  grave  condition  of  shock,  and 
reaction  may  not  occur,  although  it  has  been  observed  in 
cases  where  the  temperature  was  as  low  as  90°  F.  (32°  C). 

Prophylaxis. — Unfortunately,  many  of  the  worst  cases 
of  shock  are  due  to  accidents,  and  here  treatment  can  be 
directed  only  to  the  condition  of  shock  itself;  but  the 
surgeon  is  often  able  to  diminish  to  some  extent  the  amount 
of  shock  following  operations  by  judicious  prophylactic 
treatment.  In  patients  in  whom  shock  is  apt  to  be  mark- 
edly developed,  as  in  children  or  feeble  or  aged  subjects, 
or  in  certain  classes  of  operations,  he  may  give  stimulants 
before  the  operation,  and  see  that  the  surface  of  the  body 
is  not  unnecessarily  exposed  to  chilling  during  the  opera- 
tion, that  the  operation  is  not  needlessly  prolonged,  and 


SHOCK.  317 

that  as  little  blood  as  possible  is  lost  during  its  perform- 
ance. The  electro-thermic  mattress  may  be  used  with  ad- 
vantage, but  care  should  be  exercised  in  its  employment, 
as  serious  I  turns  have  followed  its  use.  The  previous 
administration  of  an  ounce  of  whiskey  and  the  hypo- 
dermic injection  of  from  ^  to  ^V  of  a  grain  of  sulphate 
of  strychnine,  and  the  use  of  a  small  dose  of  morphine,  in 
feeble  and  aged  patients,  will  be  followed  by  good  results. 
A  full  dose  of  quinine  given  an  hour  or  two  before  the 
operation  is  also  said  to  arrest  the  development  of  shock. 

Treatment. — The  first  indication  in  the  treatment  of 
shock  is  to  establish  reaction.  The  patient  should  be  cov- 
ered with  woollen  blankets,  the  head  should  be  kept  low, 
and  dry  heat  should  be  applied  to  the  surface  of  the  body 
by  means  of  hot-water  bags,  hot  bottles,  or  hot  bricks ; 
these  should  be  wrapped  in  towels  to  prevent  them  from 
coming  directly  in  contact  with  the  surface;  neglect  of 
this  precaution,  which  is  most  important  if  the  patient  is 
unconscious,  often  produces  burns  which  may  be  followed 
by  extensive  sloughing.  If  the  patient  can  swallow,  he 
should  be  given  small  quantities  of  whiskey  or  brandy, 
with  30  minim  doses  of  aromatic  spirit  of  ammonia,  and, 
as  absorption  by  the  stomach  is  probably  very  slow  in 
these  cases,  stimulants  should  be  administered  hypoder- 
micallv  ;  in  our  judgment,  strychnine  is  the  most  valuable 
stimulant  that  can  be  employed.  From  -gL-  to  2V  of  a 
grain  should,  therefore,  be  injected,  and  the  injection  re- 
peated every  hour  or  half-hour  until  several  doses  have 
been  given.*  Caffeine  citrate  in  doses  of  grs.  ij  may  also 
be  used  with  good  results.  Sulphuric  ether,  30  minims, 
mav  also  be  injected  into  the  cellular  tissues  at  intervals, 
as  well  as  digitalin  or  tincture  of  digitalis. 

If  shock  develops  during  an  operation  under  ether  anes- 
thesia, the  use  of  ether  hypodermically  is  contrainclicated. 
A  stimulating  enema  of  whiskey  and  warm  water  may  be 
emploved.  In  cases  of  shock  where  there  is  profuse 
sweating,  the  use  of  -^  of  a  grain  of  atropine,  repeated 
as  required,  is  often  followed  by  good  results.  A  large 
enema  of  warm  saline  solution  may  also  be  employed.     As 


318  MINOR  SURGERY. 

patients  often  complain  of  urgent  thirst,  it  is  well  to  let 
them  take  a  little  black  coffee,  but  not  large  quantities  of 
water ;  free  indulgence  in  water  does  not  seem  to  quench 
the  thirst,  and  is  apt  to  be  followed  by  vomiting.  Intra- 
venous injection  of  saline  solution  is  likely  to  be  of  most 
service  when  the  condition  has  been  preceded  by  the  loss 
of  a  large  quantity  of  blood.  Infusion  of  saline  solution 
also  has  been  employed  with  good  results. 


DRESSING  OF  WOUNDS. 

Incised  Wounds. — These  wounds  present  the  condi- 
tions favorable  for  prompt  healing,  and  after  sterilizing 
the  surrounding  skin  they  should  first  be  carefully  irri- 
gated with  saline  solution  or  sterilized  water,  to  remove 
any  blood-clots  or  foreign  bodies,  or  wiped  with  a  ster- 
ilized gauze  pledget ;  and  after  any  hemorrhage  which 
is  present  is  controlled  by  the  use  of  ligatures,  if  the 
wound  be  an  extensive  or  deep  one,  provision  should  be 
made  for  drainage  by  introducing  a  drainage-tube  or  a  few 
strands  of  sterilized  catgut  at  the  bottom  of  the  wound, 
allowing  the  ends  to  project  from  the  most  dependent 
portion  of  the  wound.  Irrigation  of  the  wound  with  a 
1  :  2000  or  1  :  4000  bichloride  solution  may  be  employed 
if  there  is  reason  to  suppose  the  wound  has  been  infected 
before  coming  under  treatment.  In  superficial  incised 
wounds,  after  the  hemorrhage  has  been  controlled,  it  is  not 
usually  found  necessary  to  make  provision  for  drainage.  If 
the  wound  be  a  deep  one,  involving  the  muscles  and  deep 
fascia,  buried  sutures  of  catgut  or  silk  should  be  applied 
to  approximate  the  muscles  and  fascia ;  and  if  important 
nerves  or  tendons  have  been  divided,  their  ends  should  be 
brought  into  apposition  by  sutures  of  catgut  or  sterilized 
silk  ;  the  superficial  portions  of  the  wound  should  next  be 
brought  together  by  the  introduction  of  a  number  of 
interrupted  sutures,  catgut,  silkworm-gut,  silver  wire,  or 
silk  being  employed  for  this  purpose ;  the  accurate  appo- 
sition of  the  edges  of  wounds  of  this  variety  is  secured  by 


LACERATED    WOUNDS.  319 

the    introduction  of  a  number  of  sutures  placed  closely 
together. 

After  a  wound  of  this  variety  has  been  closed,  the  sub- 
sequent dressing  is  accomplished  by  covering  the  surface 
of  the  wound  with  a  number  of  layers  of  sterilized  gauze 
and  a  pad  of  sterilized  cotton,  which  are  held  in  place  by  a 
gauze  bandage.  Or  a  few  layers  of  gauze,  which  have 
been  soaked  in  a  1  :  2000  bichloride  solution,  may  be 
applied  to  the  wound,  and  over  this  is  laid  a  pad  of  ster- 
ilized dry  bichloride  gauze  of  the  same  thickness,  over- 
lapping the  wet  gauze  by  a  few  inches  in  all  directions ; 
a  few  layers  of  bichloride  cotton  are  next  applied  over 
the  gauze  dressings,  and  the  whole  dressing  is  secured  in 
position  by  the  application  of  a  gauze  bandage.  Under 
this  form  of  dressing  prompt  healing  of  incised  wounds 
is  the  rule,  and  the  wound  need  not  be  redressed  for  a 
week  or  ten  days  unless  some  indications  exist  for  change 
of  dressing  at  an  earlier  period.  At  the  time  of  the  first 
dressing  the  catgut  drain  or  the  drainage-tube  is  usually 
removed,  and  if  adhesion  of  the  edges  of  the  wound  is  firm 
the  sutures  may  also  be  removed.  A  sterilized  or  bichlo- 
ride gauze  dressing  is  usually  next  applied,  and  allowed 
to  remain  for  a  few  days  longer. 

In  superficial  incised  wounds  involving  only  the  skin 
and  cellular  tissue  if  limited  in  extent,  after  cleansing  the 
wound  and  controlling  the  bleeding  the  edges  should  be 
approximated  with  sutures.  The  wound  should  then  be 
covered  with  strips  of  sterilized  gauze,  over  which  is 
painted  a  mixture  of:  tr.  benzoin,  3J  ;  collodion,  Jjvij. 
This  forms  a  firm  antiseptic  scab  which  need  not  be 
removed  until  the  wound  has  healed. 

Lacerated  Wounds. — These  present  edges  which  are 
torn  and  not  sharply  cut,  and  the  vitality  of  the  injured 
parts  is  often  so  seriously  impaired  that  prompt  union 
in  this  variety  of  wounds  is  not,  as  a  rule,  to  be  looked 
for.  Wounds  of  this  nature  should  first  be  irrigated  with 
saline  solution,  sterilized  water,  or  a  1  :  2000  bichloride 
solution,  and  blood-clots  and  foreign  bodies  removed. 
If  the  wounds  be  deep,  drainage-tubes  should  be  intro- 


320  MINOR  SURGERY. 

duced ;  on  the  other  hand,  if  they  be  superficial,  or  if  the 
edges  are  not  closely  approximated,  provision  for  drainage 
may  be  omitted.  The  torn  or  irregular  edges  of  the 
wound  should  next  be  brought  into  apposition  at  a  few 
points,  by  the  introduction  of  catgut  or  silkworm-gut 
sutures,  applied  not  very  closely  together ;  and  if  the 
edges  are  discolored  and  their  vitality  seems  markedly 
impaired,  it  is  better  not  to  use  sutures.  If  the  edges  of 
the  wound  are  so  much  crushed  that  their  vitality  is 
destroyed,  they  may  be  trimmed  away  with  scissors  until 
a  surface  possessing  a  fair  vitality  is  secured.  The  evil 
results  arising  from  the  introduction  of  sutures  into  this 
variety  of  wounds,  with  the  idea  of  closely  approximating 
their  edges,  are  so  common  that  the  surgeon  who  dispenses 
with  the  use  of  sutures  entirely  errs  upon  the  safe  side. 
The  use  of  many  sutures  in  wounds  of  this  nature  often 
causes  marked  tension,  which  is  frequently  followed  by 
impairment  of  the  vitality  of  the  injured  tissues,  and 
sloughing  results.  The  wound  should  next  be  dressed 
with  sterilized  gauze  and  cotton,  or  a  bichloride  gauze 
dressing  may  be  employed,  and  if  it  runs  a  favorable 
course  it  need  not  be  redressed  for  a  week  or  ten  days ; 
the  time  required  for  repair  of  a  wound  of  this  nature  is 
longer  than  that  for  an  incised  wound,  and  more  frequent 
dressing  may  be  required. 

In  lacerated  wounds  of  the  extremities  continuous  irri- 
gation of  the  wound  by  a  warm  bichloride  or  carbolic  solu- 
tion, applied  as  described,  is  often  followed  by  the  most 
satisfactory  results  ;  wounds  produced  by  machinery  and 
railway  accidents,  in  which  the  vitality  of  the  tissues  is 
much  impaired,  are  particularly  suitable  cases  for  this 
method  of  treatment,  and  here  the  same  caution  should 
be  exercised  as  regards  the  introduction  of  sutures. 

Contused  Wounds. — This  variety  of  wounds  possesses 
many  characteristics  in  common  with  lacerated  wounds  : 
the  edges  are  bruised  and  the  injury  of  the  subcutaneous 
tissue  is  often  more  extensive  than  the  external  wound 
would  lead  one  to  suspect.  They  are  dressed  in  the  same 
manner  as  lacerated  wounds,  and  the  same  objection  here 


POISONED    WOUNDS.  321 

exists  to  the   use    of  sutures  as  in   the    latter   class   of 
injuries. 

Punctured  Wounds. — These  wounds  are  inflicted  by 
sharp-pointed  instruments,  and  it  may  happen  that  a  por- 
tion of  the  vulnerating  body  remains  in  the  wound,  as 
is  frequently  the  case  in  wounds  produced  by  needles, 
splinters  of  wood,  metal,  or  glass ;  another  complication 
in  this  variety  of  wound  is  the  injury  of  vessels,  giving 
rise  to  concealed  hemorrhage,  or  of  nerves,  resulting  in 
neuritis  or  neuralgia.  Simple  punctured  wounds  should 
be  irrigated  with  1  :  2000  bichloride  solution  and  covered 
by  a  sterilized  or  bichloride  gauze  dressing,  and  if  no 
complication  exists  their  healing  is  usually  very  rapid. 

A  very  serious  form  of  punctured  wounds  arises  from 
the  impaling  of  a  portion  of  the  body  by  pieces  of  wood 
or  metal,  the  part  being  transfixed  or  simply  penetrated  ; 
the  penetrating  object  may  break  off,  leaving  a  portion  of 
it  in  the  wound,  or  may  retain  its  position  in  the  body,  so 
that  it  is  difficult  to  separate  the  body  from  it.  This  acci- 
dent usually  results  from  persons  falling  upon  sharp  sticks, 
wooden  or  iron  palings. 

AVhen  a  foreign  body  remains  in  the  wound,  as  often 
happens  in  punctured  wounds  produced  by  needles  and 
splinters,  the  punctured  wound  should  be  converted  into 
an  incised  wound,  and  the  body  should  be  searched  for 
and  removed ;  in  doing  this  in  the  case  of  wounds  of  the 
extremities  the  operation  is  much  facilitated  by  the  em- 
ployment of  Esmarch's  bandage.  The  Eontgen  or  .r-rays 
may  be  employed  with  advantage  in  locating  foreign 
bodies,  such  as  pieces  of  glass  or  metal,  in  punctured 
wounds.  After  the  removal  of  the  foreign  body  the  wound 
is  treated  as  an  incised  wound,  and  an  antiseptic  dressing 
should  be  applied.  When  concealed  hemorrhage  occurs 
after  a  punctured  wound,  the  wound  should  be  laid  open 
and  the  bleeding  vessel  searched  for  and  ligated  if  pos- 
sible, and  the  wound  should  afterward  be  dressed  as  an 
incised  wound. 

Poisoned  Wounds. — These  wounds  are  caused  by  the 
absorption,  by  means  of  a  cut  or  abrasion  in  the  skin,  or 

21 


322  MINOR  SURGERY. 

by  the  sweat  or  sebaceous  glands,  of  fluids  from  a  dead 
body  iu  making  dissections  or  post-mortem  examinations, 
or  in  operating  upon  living  subjects,  and  often  result  in 
serious  consequences.  Infection  occurring  from  a  living 
subject  iu  operating  is  apt  to  give  rise  to  a  similar  specific 
infection,  or  a  mixed  infection  may  result ;  whereas  infec- 
tion occurring  from  dead  bodies  is  usually  caused  by  the 
bacteria  of  putrefaction,  as  infective  micro-organisms 
retain  their  virulence  for  only  a  short  time  after  death. 
Such  wounds,  as  soon  as  possible  after  their  reception, 
should  be  carefully  washed  out  with  a  solution  of  bichlo- 
ride of  mercury,  1 :  2000,  or  a  30-grain  solution  of  chloride 
of  zinc,  and  then  dressed  with  an  antiseptic  dressing.  If, 
however,  this  precaution  is  not  taken,  or  the  wound  has 
escaped  notice,  and  in  a  few  hours  becomes  inflamed  and 
painful,  and  evidences  of  lymphatic  involvement  show 
themselves,  the  wound  should  be  opened  and  its  surface 
should  be  thoroughly  washed  out  with  a  30-grain  solution 
of  chloride  of  zinc,  and  finally  with  a  1  :  2000  bichloride 
solution,  and  it  should  then  be  dressed  with  an  antiseptic 
gauze  dressing.  Under  this  method  of  dressing,  the  poi- 
soned wound  is  often  converted  into  a  healthy  one,  even 
after  the  lymphatic  involvement  is  well  marked,  and  it 
usually  heals  promptly  without  further  constitutional 
disturbance. 

Gunshot  Wounds. — These  wounds  are  produced  by 
small  shot,  or  fragments  of  shells,  and  are  of  the  nature 
of  contused  and  lacerated  wounds,  and  the  vulnerating 
body  as  well  as  portions  of  the  clothing  is  often  imbedded 
in  the  tissues. 

The  modern  small  arms  ball  has  much  greater  velocity 
than  the  leaden  ball  formerly  employed  ;  it  has  great 
penetrating  power,  and  is  more  apt  to  pass  through  the 
bones  without  comminuting  them.  Primary  hemorrhage 
is  also  more  common  in  injuries  produced  by  this  ball. 
Within  a  certain  range  it  also  possesses  marked  explosive 
action,  producing  great  destruction  of  the  tissues  with 
which  it  comes  in  contact,  which  has  been  recently 
explained  upon  the  theory  of  hydrodynamic  pressure  or 


CONTUSIONS  OR  BBUISES.  323 

vibratory  action.  The  explosive  effect  of  a  small  calibre 
ball  depends  upon  its  velocity,  striking  energy,  area 
of  impact,  and  the  resistance  to  be  overcome,  so  that 
the  damage  to  the  tissues  in  gunshot  injuries  is  always 
greater  at  short  range,  and  decreases  with  the  increase 
of  distance.  Stevenson  now  maintains  that  the  conclu- 
sions drawn  from  experiments  upon  dead  animals  and 
men  are  not  borne  out  by  what  is  observed  when  living 
men  are  wounded  by  small  calibre  projectiles.  In  dress- 
ing these  wounds  any  foreign  bodies,  if  they  can  be 
located,  should  be  removed,  and  in  the  search  for  and 
removal  of  balls  from  the  extremities  the  application  of 
the  Esmarch  bandage  will  be  found  most  useful.  The 
a?-rays  may  also  be  satisfactorily  employed  in  locating 
balls  or  fragments  of  metal  in  gunshot  wounds.  The 
wound  should  next  be  thoroughly  washed  out  with  a 
1  :  2000  bichloride  solution,  and  an  antiseptic  dressing 
applied  as  in  the  case  of  other  contused  and  lacerated 
wounds. 

Powder-burns. — These  result  from  the  explosion  of  gun- 
powder, and,  in  addition  to  the  burning  and  laceration  of 
the  tissues,  are  accompanied  by  the  introduction  of  grains 
of  unburn t  powder  into  the  skin,  which,  if  not  removed, 
leave  permanent  points  of  pigmentation.  These  wounds 
should  first  be  washed  with  a  1  :  2000  bichloride  solution, 
and  upon  the  face,  to  avoid  unsightly  pigmentation  of  the 
skin,  care  should  be  taken  to  pick  out  the  small  masses 
of  powder  with  a  needle  or  the  sharp  point  of  a  tenotomy 
knife.  The  surface  should  then  be  dressed  with  antiseptic 
gauze  or  with  lint  spread  with  an  ointment  of  boric  acid 
or  an  ointment  of  aristol,  consisting  of  half  a  drachm  or 
a  drachm  of  aristol  to  an  ounce  of  vaseline,  this  dressing: 
being  covered  by  a  few  layers  of  gauze  and  cotton,  held 
in  place  by  a  roller-bandage. 

In  pigmented  scars  following  powder-burns,  the  powder 
grains  may  be  removed  by  electrolysis. 

Contusions  or  Bruises. — These  wounds  differ  from 
contused  wounds  in  the  fact  that  the  skin  is  not  broken, 
although  in  spite  of  this  fact  there  may  exist  very  exten- 


324  MINOR  SURGERY. 

sive  laceration  of  the  subcutaneous  tissues,  accompanied 
by  more  or  less  extravasation  of  blood  from  the  injured 
vessels.  When  not  sufficiently  severe  to  require  operative 
treatment,  they  should  be  dressed  by  applying  over  them 
several  layers  of  lint  saturated  with  lead-water  and  lauda- 
num, and  over  this  dressing  is  placed  a  layer  of  waxed 
paper  or  rubber-tissue,  and  the  dressing  is  secured  by  a 
roller-bandage.  A  solution  which  I  find  most  satisfac- 
tory in  the  dressing  of  contusions  is  as  follows :  ammonii 
chloridi,  grs.  xx  ;  tr.  opii  et  alcoholis,  aa  f  J5j  ;  aqua?,  f,?j. 
Several  layers  of  lint  saturated  with  this  solution  are  laid 
over  the  contused  tissues,  and  are  covered  with  waxed 
paper,  oiled  silk,  or  rubber-tissue. 

Extensive  collections  of  blood  following  contusions  often 
remain  in  the  tissues  for  some  time,  but  usually  are  ab- 
sorbed. If  this  result  does  not  follow,  or  an  abscess  forms, 
the  blood  or  pus  should  be  removed  by  aspiration  or  by 
incision  with  full  antiseptic  precautions. 

Brush-burn. — This  is  a  form  of  contused  and  lacerated 
wound  which  is  produced  by  violent  friction  applied  to  the 
surface  of  the  body,  and  is  often  caused  by  coming  in 
contact  with  rapidly  revolving  wheels  or  the  belting  of 
machinery,  or  by  the  body  being  rapidly  propelled  over  an 
uneven  surface,  or  by  a  rope  being  rapidly  drawn  through 
the  closed  hands.  The  injury  may  vary  from  a  superficial 
abrasion  to  absolute  destruction  of  the  skin.  The  sur- 
face of  the  brush-burn  should  be  cleansed  by  a  stream  of 
normal  salt  solution,  sterilized  water,  or  1  :  2000  bichloride 
solution,  and  then  dressed  with  a  powder  of  acetanilid  and 
boric  acid,  equal  parts,  and  a  sterilized  gauze  dressing  ap- 
plied ;  if  suppuration  occurs,  a  moist  bichloride  or  acetate 
of  aluminum  dressing  or  boric  acid  ointment  should  be 
applied. 

Burns  and  Scalds. — The  dressings  employed  in  the 
treatment  of  burns  and  scalds  are  similar,  as  the  injury  to 
the  tissues  is  practically  the  same  in  both  classes  of  injuries. 
Superficial  burns  or  scalds,  in  which  the  effect  of  the  heat 
has  extended  only  to  the  superficial  layer  of  the  skin,  may 
be  treated  by  the  application  of  lint  saturated  Avith  a  solu- 


BURXS  AXD  SCALDS.  325 

tion  of  carbonate  of  sodium,  a  drachm  to  an  ounce  of  water  ; 
this  dressing  rapidly  relieves  the  pain,  and  is  a  satisfactory 
application  in  this  variety  of  burns  and  scalds.  In  cases 
in  which  the  effects  of  heat  have  extended  to  the  deeper 
tissues,  the  affected  surface  may  be  dressed  with  Carron  oil, 
which  is  prepared  by  rubbing  together  lime-water  and  lin- 
seed oil  until  a  thick,  creamy  paste  results  ;  lint  is  saturated 
with  this  mixture  and  laid  over  the  surface  of  the  burn  or 
scald.  This  dressing  is  a  comfortable  one  to  the  patient, 
but  possesses  no  antiseptic  qualities  and  soon  becomes 
offensive,  and  for  this  reason  requires  frequent  renewal. 

White-lead  Dressing. — This  application,  which  con- 
sists of  white  lead  (Iviij),  powdered  acacia  (oij),  sodium 
bicarbonate  (gj),  and  linseed  oil  (a  sufficient  quantity  to 
make  a  mixture  of  the  consistency  of  thick  cream),  is  ex- 
tensively used  in  the  coal  regions  of  Pennsylvania,  where 
severe  burns  are  very  frequent.  It  is  spread  upon  lint  or 
gauze  and  applied  to  the  burned  surfaces  ;  it  does  not  re- 
quire frequent  renewal,  and  repair  of  the  injured  surfaces 
is  rapid  under  its  use. 

The  disadvantage  met  with  in  the  antiseptic  method  of 
dressing  burns  and  scalds  is  the  fact  that  the  raw  surface 
presented  offers  most  favorable  conditions  for  absorption 
of  the  antiseptic  substances  employed  in  the  dressings, 
and  for  this  reason  the  use  of  bichloride  of  mercury,  car- 
bolic acid,  and  iodoform  is  not  to  be  recommended  in 
burns  or  scalds  involving  a  large  extent  of  surface,  on 
account  of  the  toxic  symptoms  which  may  result  from 
their  absorption. 

In  Germany  the  treatment  of  extensive  burns  by  con- 
tinuous immersion  of  the  patient  in  a  warm  bath  has  been 
followed  by  good  results. 

Asa  recent  burn  or  scald,  by  reason  of  the  heat  employed 
in  its  production,  is  practically  an  aseptic  wound,  a  simple 
sterilized  dressing  may  be  employed.  It  may  be  dressed 
by  covering  it  with  a  number  of  layers  of  sterilized  gauze 
and  cotton,  or  with  powdered  boric  acid,  aristol,  or  acetan- 
ilid,  and  placing  over  this  a  number  of  layers  of  sterilized 
cotton,   holding   the  dressings   in   position  by  a  bandage. 


32b*  MINOR  SURGERY. 

If,  however,  a  full  antiseptic  dressing  is  employed,  the 
injured  surface  should  first  be  irrigated  with  a  1  :4000 
bichloride  solution,  and  then  covered  with  protective  or 
rubber-tissue  which  has  been  sterilized,  and  over  this  a 
dressing  of  bichloride  or  sterilized  gauze  and  bichloride 
cotton  should  be  applied.  If  this  dressing  is  employed, 
the  patient  should  be  carefully  watched  for  the  develop- 
ment of  toxic  symptoms. 

When  blebs  are  present  upon  the  surface  of  the  burn  or 
scald,  they  should  be  opened  to  allow  the  serum  to  escape. 
If  suppuration  occurs,  or  the  tissues  become  necrosed  by 
reason  of  the  severity  of  the  injury,  the  surface  of  the  burn 
may  be  irrigated  with  normal  salt  solution  or  a  1  :  4000 
bichloride  solution,  and  the  same  dressing  should  then  be 
applied. 

Ulcers  resulting  from  separation  of  the  dead  tissues 
should  be  touched  with  a  solution  of  nitrate  of  silver,  5 
grains  to  the  ounce  of  water,  and  dressed  with  lint  spread 
with  an  ointment  of  boric  acid,  aristol,  or  ichthyol.  In 
the  dressing  of  extensive  burns  or  scalds  of  the  neck,  face, 
and  region  of  the  joints,  the  possibility  of  serious  defor- 
mity from  contraction  of  the  tissues  in  healing  should  not 
be  lost  sight  of,  and  position,  splints,  and  bandages  should 
be  employed  to  prevent,  as  far  as  possible,  this  complica- 
tion. 

Injuries  from  Electricity. — Since  the  extensive  intro- 
duction of  electricity  in  the  arts,  injuries  from  contact  with 
heavily  charged  wires  are  of  frequent  occurrence.  If  the 
current  be  a  strong  one,  death  may  be  instantaneous,  or 
the  patient  may  be  knocked  down,  become  unconscious, 
and  present  severe  burns  at  the  point  of  contact,  then 
regain  consciousness,  and  subsequently  suffer  from  numb- 
ness in  the  extremities,  traumatic  neuroses,  and  in  rare 
cases  true  paralysis.  If  the  skin  be  dry  at  the  time  the 
current  is  received,  there  will  be  more  burning,  less  pene- 
tration and  less  shock,  and  less  danger  of  death.  The 
burns  are  not  painful,  but  are  apt  to  be  followed  by  exten- 
sive sloughing.  Alternating  currents  are  more  dangerous 
than  continuous  currents ;   a  continuous  current  of  one 


INJURIES  FROM  ELECTRICITY.  327 

thousand  volts  is  not  apt  to  be  followed  by  serious  conse- 
quences, whereas  an  alternating  current  of  the  same  strength 
is  likely  to  produce  death. 

Death  from  exposure  to  strong  alternating  currents  is 
considered  by  Hedley  to  be  caused  by  destruction  of  the 
tissues  or  by  arrest  of  respiration  producing  asphyxia. 
Exposure  to  a  strong  electric  current  may  produce  burns 
or  ecchymoses,  and  occasionally  wounds ;  the  latter  bleed 
freely  and  are  apt  to  slough.  A  burn  from  electricity 
presents  a  dry  blackened  surface  and  is  surrounded  by  an 
area  of  pale  skin.  They  are  not  as  painful  as  ordinary 
burns,  but  healing  in  electric  burns  is  usually  slow.  In- 
flammation and  suppuration  of  the  tissues  usually  develop 
in  a  few  days,  and  are  often  followed  by  the  development 
of  an  extensive  area  of  moist  gangrene,  a  small  burn 
being  followed  by  extensive  and  deep  destruction  of  the 
surrounding  tissues. 

Treatment. — The  treatment  of  a  person  who  has  been 
exposed  to  a  strong  electric  current,  even  if  apparently 
lifeless,  consists  in  practising  artificial  respiration,  Laborde's 
or  Silvester's  method  being  employed ;  also  friction  to  the 
surface  of  the  body  and  enemata  of  hot  saline  solution  ;  in 
some  cases  venesection  has  been  employed  with  advantage. 
Hedlev  records  a  case  of  apparent  death  in  a  man  who 
received  an  alternating  current  of  four  thousand  five 
hundred  volts  short-circuited  through  his  body  for  many 
minutes,  who  showed  no  signs  of  life  for  thirty  minutes. 
In  this  case,  after  the  employment  of  Laborde's  method 
of  artificial  respiration  for  some  time,  normal  respiratory 
action  was  restored,  and  the  patient  recovered.  Artificial 
respiration  should  be  practised  in  all  cases,  and  should  be 
continued  until  it  is  certain  that  the  patient  is  dead.  At 
the  same  time  strychnine  should  be  used  hypodermically. 

The  burns  should  be  treated  by  the  application  of  anti- 
septic dressings,  but  these  often  fail  to  arrest  the  sloughing. 
DaCosta  recommends  in  the  early  stage  of  these  burns 
the  use  of  fomentations  of  hot  saline  solution,  which  facili- 
tates separation  of  the  sloughs,  and  in  the  subsequent 
dressing  of  the  wounds  peroxide  of  hydrogen  followed  by 


328  MINOR  SURGERY. 

irrigation  with  saline  solution.  After  the  sloughs  have 
separated,  dry  sterilized  dressings  should  be  employed. 

Lightning- stroke. — In  this  form  of  electric  injury  a 
person  may  be  struck  directly  or  may  be  shocked  by  an 
induced  current,  the  lightning  having  struck  some  object 
near  at  hand.  The  results  of  lightning-stroke  upon  the 
body  differ  according  as  the  electrical  or  the  burning 
action  predominates.  There  may  be  present  severe  burns  or 
extensive  lacerations,  involving  the  muscles,  bloodvessels, 
and  bones ;  or  sudden  death  may  result  from  paralysis  of 
the  respiration  and  circulation.  Upon  regaining  conscious- 
ness, the  patient  may  complain  of  disturbance  of  vision, 
and  may  suffer  from  paralysis  of  the  nerves  of  motion  or 
sensation  ;  paralysis  of  the  lower  limbs  is  said  to  be  more 
common  than  that  of  the  upper  limbs. 

Treatment. — The  treatment  of  the  stage  of  shock  follow- 
ing lightning-stroke  consists  in  the  application  of  external 
heat,  the  employment  of  artificial  respiration,  and  the 
administration  of  stimulants.  If  burns  exist  upon  the 
surface  of  the  body,  they  should  be  treated  like  burns 
arising  from  artificial  currents.  If  paralysis  persists  for 
some  time  after  recovery. from  the  immediate  effects  of  the 
shock,  the  use  of  galvanism  and  the  administration  of 
strychnine  may  be  followed  by  good  results. 

X-Ray  Burns. — A  peculiar  lesion  of  the  skin  and  sub- 
jacent tissues,  following  prolonged  exposure  to  the  ay-rays, 
resulting  in  ulceration  of  the  skin  and  loss  of  the  nails 
and  hair  in  the  damaged  area,  is  described  as  an  ;r-ray 
burn.  This  lesion  differs  from  an  ordinary  burn  in  that 
it  may  not  appear  for  several  days  or  weeks  after  the 
exposure,  and  that  the  inflammatory  or  gangrenous  process 
arises  in  the  tissues  and  finally  involves  the  skin.  These 
lesions  are  very  painful  and  slow  in  healing;  and  if  an 
extensive  surface  be  involved,  they  may  result  in  serious 
consequences  :  amputation  of  the  limb  has  been  demanded 
by  reason  of  a  burn  of  this  nature.  The  lesion  is  prob- 
ably due  to  trophic  changes. 

Treatment. — The  dressings  employed  in  ordinary  burns 
have  not  proved  satisfactory  in  these  injuries.     Dry  steril- 


BEDSORES.  329 

ized  dressings  may  be  employed,  and  skin-grafting  when 
the  ulcerated  surface  is  extensive  may  be  of  service. 
When  a  small  area  only  is  involved,  and  healing  fails 
to  occur,  Powell  recommends  excision  of  the  ulcerated 
tissues. 

Bedsores. — These  sores  usually  occur  over  the  sacrum 
or  hips  in  patients  who  are  confined  to  bed  for  a  consider- 
able time,  as  the  result  of  long-continued  pressure,  or  in 
cases  where  the  vital  powers  are  depressed  by  ady- 
namic diseases,  and  are  also  a  frequent  and  troublesome 
complication  in  spinal  injuries,  in  which  cases  they  result 
from  trophic  disturbances.  Their  formation  may  be  pre- 
vented in  many  cases  by  the  use  of  air-cushions  or  of  a 
water  mattress,  and  by  keeping  the  parts  exposed  to  press- 
ure scrupulously  clean  and  frequently  bathing  them  with 
stimulating  lotions,  such  as  alcohol,  olive  oil  and  alcohol 
(equal  parts),  or  soap  liniment.  The  parts  should  also  be 
protected  from  pressure  by  the  application  of  adhesive 
plaster,  or,  still  better,  soap  plaster  spread  upon  chamois 
skin.  When  a  bedsore  has  actually  formed — and  in  many 
cases  its  formation  is  very  rapid  and  the  slough  will  be 
found  to  involve  a  large  surface  of  the  skin  over  the  sac- 
rum, and  to  extend  down  to  the  bone — we  have  present  a 
very  serious  complication,  and  one  which  requires  most 
careful  treatment. 

The  dressing  of  a  bedsore  before  separation  of  the 
slough  consists  in  relieving  the  part  from  pressure  by  the 
use  of  an  air-cushion  placed  under  the  buttocks,  and  the 
application  of  a  moist  antiseptic  dressing  until  the  slough 
has  separated.  When  the  slough  has  become  detached,  the 
ulcer  remaining  should  be  well  irrigated  with  a  1  :  2000 
bichloride  solution,  and  the  granulations  touched  with 
a  o-grain  solution  of  nitrate  of  silver ;  and  aristol,  or 
boric  acid  ointment  spread  upon  lint,  should  be  applied 
to  the  surface  of  the  ulcer,  and  a  piece  of  soap  plaster  a 
little  larger  than  the  ulcer  should  be  placed  over  this  dress- 
ing and  held  in  place  by  broad  strips  of  adhesive  plaster. 
This  dressing  should  be  renewed  every  day  or  every  other 
day,  and  means  should  be  adopted  to  protect  the  parts 


330  MINOR  SURGERY. 

from  farther  pressure,  and  the  constitutional  condition  of 
the  patient  should  be  improved  by  the  administration  of  a 
nutritious  diet,  tonics,  and  stimulants.  The  application 
of  the  galvanic  current  has  been  employed  to  promote 
healing  of  the  ulcer  in  obstinate  cases. 

Sprains. — Sprains  of  the  joints  from  twists  or  other 
external  violence  resulting  in  the  stretching  or  laceration  of 
the  ligaments  are  injuries  which  require  careful  dressing. 

Sprains  may  be  first  treated  by  the  application  of  cold- 
water  or  hot-water  dressings  for  a  few  hours,  or  by  the 
application  of  lead-water  and  laudanum,  the  joint  being 
kept  at  rest  by  the  use  of  a  splint  or  by  confining  the 
patient  in  the  recumbent  posture  in  the  case  of  sprains  of 
the  joints  of  the  lower  extremities. 

After  a  few  days'  use  of  the  lead-water  and  laudanum 
dressing  the  swelling  usually  subsides,  and  the  joint  may 
be  fixed  by  the  application  of  a  moulded  soap-plaster  splint 
or  felt  splint  held  in  place  by  a  firmly  applied  roller-band- 
age, which  should  be  worn  for  a  week  or  ten  days  ;  in 
ordinary  cases  after  this  time  the  splint  may  be  removed 
and  the  patient  should  be  encouraged  to  use  the  joint.  In 
cases  of  severe  sprains,  on  the  other  hand,  the  pain  and 
swelling  persist  for  some  time,  and  here  the  fixation  of  the 
joint  by  a  plaster-of-Paris  bandage  will  be  found  useful 
for  a  few  weeks. 

In  the  chronic  stage  of  a  sprain,  after  all  dressings  have 
been  removed,  the  methodical  use  of  massage  is  often  most 
beneficial ;  and  after  the  parts  have  been  thoroughly  man- 
ipulated a  flannel  bandage  should  be  applied,  which,  by  its 
elasticity,  gives  a  certain  amount  of  support  to  the  parts. 

Strapping. — The  treatment  of  sprains  which  I  have  found 
the  most  satisfactory,  both  in  the  acute  and  chronic  stage, 
consists  in  the  use  of  strapping.  Strips  of  adhesive  or 
rubber  adhesive  plaster  one  and  a  half  inches  in  width  are 
applied  around  the  joint,  and  are  made  to  extend  some 
distance  above  and  below  it;  a  gauze  bandage  is  next 
applied  over  the  straps,  and  the  patient  is  allowed  to  use 
the  part  as  soon  as  he  can  do  so  without  discomfort  (see 
page  176). 


SPRAIN-FRACTURE.  331 

Sprain-fracture. — Under  this  name  Mr.  Callender  has 
described  an  injury  which  consists  in  the  separation  of  a 
ligament  or  tendon  from  its  point  of  insertion  into  a  bone, 
with  the  detachment  of  a  thin  shell  of  the  bone ;  this 
injury  is  apt  to  occur  about  the  ankle-joint,  knee-joint, 
elbow-joint,  and  wrist-joint,  and  the  treatment  is  the 
same  as  that  of  an  ordinary  fracture  in  the  same  locality. 
This  injury  is  probably  much  more  common  than  is  gen- 
erally supposed  in  connection  with  sprains  of  the  joints, 
and  is,  I  think,  in  many  cases  the  cause  of  tardy  restora- 
tion of  the  function  of  sprained  joints,  this  injury  being 
overlooked,  simply  being  treated  as  a  sprain,  and  the 
patient  being  encouraged  to  use  the  part  before  union  of 
the  bone  has  been  accomplished. 

Strains  of  Muscles  and  Fascia. — These  vary  in  sever- 
ity from  simple  stretching  of  the  fibres  to  absolute  rupt- 
ure, and  should  be  treated  by  putting  the  parts  at  rest  and 
by  the  application  of  pressure  by  means  of  adhesive  straps 
or  of  a  bandage  ;  in  strains  of  the  muscles  and  fascia  of  the 
back  the  use  of  broad  strips  of  adhesive  plaster,  applied 
as  in  cases  of  fracture  of  the  ribs,  will  be  found  most  sat- 
isfactory. In  the  treatment  of  the  later  stages  of  these 
injuries  the  employment  of  massage  will  often  be  followed 
by  good  results. 


PAET    III. 

FRACTURES. 


In  the  following  section  the  author  has  endeavored  to 
confine  himself  simply  to  a  description  of  the  varieties  of 
fracture  and  to  their  dressing  and  treatment,  and  he  has 
tried  as  far  as  possible  to  avoid  the  multiplication  of 
dressings,  being  satisfied  to  describe  a  few  of  the  methods 
of  dressing  most  frequently  employed.  He  has  also 
avoided  the  description  of  complicated  splints  and  dress- 
ings, by  the  use  of  which  in  certain  fractures  most  excel- 
lent results  are  obtained,  but  has  preferred  to  recommend 
the  employment,  of  simple  splints  and  dressings,  which 
can  be  obtained  by  physicians  practising  in  districts 
remote  from  large  cities,  where  the  services  of  an  instru- 
ment-maker cannot  be  obtained  to  construct  special  appa- 
ratus for  the  treatment  of  these  injuries. 


VARIETIES  OF  FRACTURE. 

Complete  Fracture. — This  is  a  fracture  in  which  the 
line  of  separation  completely  traverses  the  bone,  involv- 
ing its  entire  thickness. 

Incomplete  Fracture. — This  is  a  fracture  in  which 
there  is  only  a  partial  separation  of  the  bone-fibres  (Fig. 
237),  under  which  name  is  included  partial  or  "green- 
stick  "  fracture,  in  which  some  of  the  bone-fibres  have 
given  way,  while  the  remaining  fibres  have  been  bent  by 

333 


334  FRACTURES. 

the  force  but  have  not  been  broken  (Fig.  238).  Fissured, 
punctured,  indented,  and  perforating  fractures  are  also 
included  in  the  class  of  incomplete  fractures  (Fig.  239). 

Fig.  237.  Fig.  238.  Fig.  239. 


Incomplete  fracture  Partial  or  green-stick        Fissured  fracture  of  the 

of  femur.  fracture  of  radius.  humerus.    (Gurlt.) 

Subperiosteal  Fracture. — This  is  a  fracture  in  which 
the  fibres  of  the  bone  are  ruptured  but  the  periosteum  re- 
mains untorn  ;  it  is  seen  in  children. 

Gunshot  Fractures. — The  nature  of  the  injury  to  the 
bone  depends  upon  the  density  of  the  latter,  and  upon  the 
size,  shape,  composition,  and  velocity  of  the  ball.  In  gun- 
shot injury  of  the  spongy  bones  the  cancellated  structure 
yields  to  pressure,  and  the  striking  energy  is^  not  trans- 
mitted in  lateral  directions,  producing  explosive  effects; 
while  in  the  dense  bones,  such  as  the  submaxillary  bones 


VARIETIES  OF  FRACTURE.  335 

or  the  shafts  of  the  long  bones,  extensive  comminution  and 
Assuring  are  apt  to  result.  In  the  articular  ends  of  the 
long  bones  clean  perforations  are  often  observed,  except 
at  close  range,  when  more  or  less  comminution  of  the  can- 
cellated structure  may  occur.  The  tissues  from  the  wound 
of  entrance  to  the  bone  are  usually  injured  only  in  the 
line  of  perforation,  but  those  beyond  the  seat  of  injury 
are  often  extensively  lacerated  and  contused,  not  only  by 
the  ball,  but  also  by  the  splinters  of  bone  driven  into  the 
tissues,  and  acting  as  secondary  missiles. 

Simple  or  Closed  Fracture. — This  is  a  fracture  in 
which  there  are  but  two  fragments,  and  the  seat  of  injury 
in  the  bone  does  not  communicate  with  the  external  air  by 
a  wound  in  the  soft  parts. 

Compound  or  Open  Fracture. — This  is  a  fracture  in 
which  the  seat  of  injury  in  the  bones  communicates  with 
the  external  air  by  a  wound  in  the  soft  parts. 

Comminuted  Fracture.— This  is  a  fracture  in  which 
there  are  more  than  two  fragments,  the  lines  of  fracture 
intercommunicating  with  each  other  (Fig.  240). 

Multiple  Fracture. — This  is  a  fracture  in  which  a  bone 
is  the  seat  of  two  or  more  distinct  fractures  at  different 
points,  the  lines  of  fracture  not  necessarily  communicating 
with  each  other. 

Complicated  Fracture. — This  is  a  fracture  accompanied 
by  some  serious  injury  of  the  parts  in  the  region  of  the 
fracture — as,  for  instance,  the  laceration  of  important 
bloodvessels  or  nerves,  contusion  or  laceration  of  the  mus- 
cles, or  dislocation  of  a  neighboring  joint. 

Impacted  Fracture. — This  is  a  fracture  in  which  one 
fragment  is  driven  into  and  fixed  in  the  other,  the  impac- 
tion taking  place  at  the  time  of  fracture,  or  being  caused 
by  a  force  subsequently  applied  (Fig.  241). 

Transverse  Fracture. — This  is  a  fracture  in  which  the 
general  line  of  division  of  the  bone  is  at  right  angles  with 
the  long  axis  of  the  bone  (Fig.  242).  Transverse  fract- 
ures of  the  long  bones  are  rarely  met  with,  the  line  of 
fracture  usually  being  more  or  less  oblique. 

Oblique  Fracture. — This  is  a  fracture  in  which  the  line 


336 


FRACTURES. 


Fig.  240. 


Fig.  242. 


Comminuted  fracture 
of  patella. 

Fig.  241. 


Impacted  fracture. 


Transverse  fracture  of 
femur.    (Gurlt.) 


of  separation  is  oblique  to  the  long  axis  of  the  bone.  This 
is  one  of  the  most  common  directions  of  the  line  of  fract- 
ure (Fig.  243). 

Longitudinal  Fracture. — This  is  a  fracture  in  which 
the  line  of  separation  runs  in  the  general  direction  of  the 
long  axis  of  the  bone  (Fig.  244).  This  form  of  fracture 
is  rare,  but  is  sometimes  met  with  in  the  long  bones  as  the 
result  of  gunshot  injury. 

Symptoms  of  Fracture. — The  most  prominent  symp- 
toms of  fracture  are  loss  of  function,  deformity,  preter- 
natural mobility,  pain,  crepitus,  and  muscular  spasm.  In 
impacted  fractures,  crepitus  and  preternatural  mobility  are 
absent. 


VARIETIES  OF  FRACTURE. 


337 


Ftg.  243. 


Fig.  244. 


ill  CI 


Oblique  fracture  of  humerus. 
(Stimson.) 


Longitudinal  fracture  of  tibia. 
(Stimson.) 


Deformity. — The  deformity  or  displacement  in  fractures 
is  either  angular,  transverse,  longitudinal,  or  rotary. 

Examination  of  Fractures. — In  examining  a  case  of 
fracture  to  locate  the  nature  and  seat  of  the  injury,  the 
clothing  should  be  removed  from  the  part  with  as  little 
disturbance  as  possible,  and  it  is  better,  in  most  cases,  to 
cut  or  rip  the  clothing  rather  than  to  attempt  to  remove 
it  in  the  ordinary  manner.  The  surgeon  should  first 
inspect  the  injured  part,  and,  where  possible,  compare  it 
with  its  fellow,  as  in  the  case  of  injuries  of  the  extremities  ; 
much  valuable  information  is  also  derived  from  the  patient 
or  his  friends  as  to  the  manner  in  which  the  injury  was 
produced.  The  part  should  next  be  carefully  examined  by 
the  surgeon  ;  if  it  be  one  of  the  extremities  which  is  in- 
22 


338  FRACTURES. 

jured,  it  should  be  gently  lifted,  firm  extension  being  made 
at  the  same  time,  the  surgeon  by  his  touch  and  by  gentle 
movements  seeking  to  locate  the  seat  of  fracture  ;  and  he 
may,  by  his  manipulation,  at  the  same  time  develop  crep- 
itus. 

All  manipulations  should  be  made  with  care,  and  with 
the  greatest  gentleness,  not  only  to  save  the  patient  from 
pain,  but  also  to  prevent  the  soft  parts  in  the  region  of  the 
fracture  from  being  injured  by  the  rough  or  sharp  frag- 
ments of  the  bone.  Rough  handling  of  fractures  may 
increase  the  muscular  spasm  by  the  irritation  caused  by 
the  sharp  fragments  of  the  bones,  and  may  also  result  in 
the  injury  of  important  vessels  and  nerves,  and  indeed  a 
simple  fracture  may  readily  be  converted  into  a  compound 
one  by  forcible  and  injudicious  manipulations. 

The  sooner  the  examination  is  made  after  fracture  has 
occurred  the  better,  for  at  this  time  there  is  less  swelling 
in  the  region  of  the  injury,  and  the  surgeon  can  locate 
the  bony  prominences  with  much  more  ease,  and  often 
discover  the  exact  seat  of  the  fracture  with  the  least 
amount  of  manipulation  of  the  parts.  When  a  case  of 
suspected  fracture  is  not  subjected  to  examination  for 
several  days  after  reception  of  the  injury,  the  parts  in  the 
region  of  the  supposed  fracture  are  often  so  much  swollen 
that  it  is  impossible  to  accurately  locate  its  seat,  and  in 
such  a  case  it  is  often  necessary  to  wait  until  the  swelling 
has  subsided  before  the  position  of  the  fracture  can  be  sat- 
isfactorily fixed,  the  case  being  treated  in  the  meantime  as 
one  of  fracture. 

Anaesthetics. — These  may  be  employed  to  relieve  the 
patient  from  pain  and  to  obliterate  muscular  spasm  in  the 
examination  of  fractures.  Their  employment  is  often  of 
the  greatest  service  in  the  diagnosis  of  obscure  or  compli- 
cated fractures,  especially  those  in  the  neighborhood  of 
joints  ;  but  the  surgeon  should  remember  that  all  manipu- 
lations should  be  made  with  the  same  gentleness  as  when 
the  examination  is  conducted  without  anaesthesia,  for  there 
is  the  same  risk  of  injury  to  the  surrounding  structures  by 
the  fragments ;  this  precaution  is  often  neglected  when  an 


PROVISIONAL  DRESSINGS  OF  FRACTURES.      339 


Fig.  245. 


anaesthetic  has  been  given,  the  surgeon  being  inclined  to 
handle  the  parts  more  roughly  than  he  otherwise  would ; 
such  practice  cannot  be  too  severely  condemned. 

The  use  of  the  fluoroscope  or  of  a  skiagraph  taken  by 
the  »-rays  has  proved  a  valuable  means  of  ascertaining 
the  existence  or  location  of  the  fracture  in  obscure  cases. 

Provisional  Dressings  of  Fractures. — It  generally 
happens  that  fractures  occur  at  localities  more  or  less  dis- 
tant from  the  point  where  the  treatment  of  the  fracture  is 
to  be  conducted,  and  the  transportation  of  the  patient  and 
the  temporary  dressing  of  the 
fracture  are,  therefore,  matters 
of  the  first  importance.  In 
fractures  of  the  upper  extremity, 
if  the  fracture  be  simple,  the 
clothing  need  not  be  removed, 
and  the  arm  should  be  bound 
to  the  side  by  some  article  of 
clothing,  or  supported  in  a 
sling  made  from  handkerchiefs 
or  the  clothing,  and  the  patient 
can  usually  walk  or  ride  for  a 
short  distance  without  much 
injury  to  the  parts  in  the  re- 
gion of  the  fracture  or  incon- 
venience to  himself.  When 
the  bones  of  the  lower  extremi- 
ties or  the  trunk  are  the  parts 
involved,  the  transportation  of 
the  patient  is  a  matter  of  more 
difficulty.  When  the  bones  of 
the  trunk  are  involved,  the 
part  should  be  surrounded  by 
a  binder  firmly  pinned  or  tied, 
made  from  the  clothing  or  from 

towels,  or  sheets,  or  other  strong  materials  which  are  at 
hand.  When  the  bones  of  the  lower  extremity  are  in- 
volved, if  the  fracture  be  a  simple  one  the  clothing  need 
not  be  removed,  and  the  motion  of  the  fragments  should 


Provisional  dressing  for  fracture  of 
the  leg.    (Esmarch.) 


340  FRACTURES. 

be  prevented  by  applying  to  the  sides  of  the  limb,  extend- 
ing above  and  below  the  seat  of  fracture,  strips  of  wood, 
shingles,  pasteboard,  bundles  of  straw,  strips  of  bark 
taken  from  trees,  or  bundles  of  twigs,  these  being  held 
in  place  by  handkerchiefs  or  strips  torn  from  the  clothing 
(Fig.  245).  Umbrellas  or  canes,  or  broomsticks,  applied 
in  the  same  manner,  may  be  employed,  the  object  of  all 
of  these  dressings  being  to  secure  temporary  fixation  of 
the  fragments  of  bone  during  the  transportation  of  the 
patient. 

If  the  fragments  are  not  fixed  in  some  way,  but  are  al- 
lowed to  move  about  during  the  transportation  of  the 
patient,  much  damage  may  result  to  the  soft  parts  sur- 
rounding the  fractured  bones,  and  simple  fractures  may 
become  compound  ones  by  the  bones  being  forced  through 
the  skin,  the  discomfort  of  the  patient  at  the  same  time 
being  much  increased. 

Having  applied  a  dressing  to  bring  about  fixation  of 
the  fragments,  the  patient  should  next  be  placed  upon  a 
broad  board  or  settee ;  if  a  mattress  cannot  be  obtained, 
the  fractured  limb  should  be  laid  upon  a  mass  of  clothing, 
or  upon  straw,  and  he  should  be  placed  in  a  wagon  or 
carried  to  the  point  where  the  subsequent  treatment  of 
the  fracture  is  to  be  conducted. 

Reduction  or  Setting  of  Fractures. — This  should  be 
effected  as  soon  as  possible  after  the  occurrence  of  the 
injury  and  as  soon  as  the  surgeon  is  prepared  to  apply  the 
dressings  to  keep  the  parts  in  their  proper  position  ;  reduc- 
tion at  an  early  period  is  less  painful  to  the  patient,  and  is 
accomplished  with  more  ease  to  the  surgeon  than  at  a  later 
period,  when  marked  inflammation  and  swelling  are  present 
at  the  seat  of  fracture.  Reduction  consists  in  bringing 
the  fragments,  by  manipulation,  as  nearly  as  possible  in 
their  normal  position  ;  this  is  accomplished  by  extension 
and  manipulation  with  the  hands,  care  being  taken  to 
use  as  little  force  as  possible  to  attain  the  object.  Very 
little  force  is  required  if  the  surgeon  places  the  part  in 
such  a  position  as  to  relax  the  muscles  which  produce  the 
displacement ;    when  this  is  accomplished,  the  fragments 


FRACTURE  DRESSINGS.  341 

can  usually  be  pressed  into  position  by  the  fingers  without 
the  application  of  considerable  force.  When  the  reduc- 
tion of  a  fracture  has  been  accomplished,  the  fragments 
are  retained  in  position  by  the  application  of  various  splints 
or  dressings  which  serve  to  prevent  their  displacement. 


MATERIALS    AND    APPLIANCES    USED    IN    THE 
DRESSING    OF    FRACTURES. 

The  Fracture  Bed. — Many  ingenious  forms  of  beds 
have  been  devised  for  the  use  of  patients  suffering  from 
fractures  of  the  bones  of  the  trunk  and  lower  extremities, 
with  the  object  of  permitting  the  patient  to  have  fecal 
evacuations  without  disturbing  his  position ;  but  a  simple 
bedstead  provided  with  a  firm  hair  mattress  is  usually 
more  satisfactory  than  the  complicated  form  of  bed. 

It  will  be  found  more  convenient  in  handling  the  patient 
to  use  a  single  bed  not  over  thirty-two  or  thirty-six  inches 
in  width,  and  it  is  not  essential  that  the  mattress  be  per- 
forated, as  a  bed-pan  can  usually  be  slipped  under  the 
patient.  The  use  of  an  ordinary  shallow  tin  pie-plate 
covered  with  a  piece  of  old  muslin  to  receive  the  fecal 
evacuations  may  be  substituted  for  the  bed-pan,  and  will 
be  found  in  many  cases  more  satisfactory,  especially  in 
the  case  of  children  suffering  from  fracture  of  the  lower 
extremity. 

Splints. — After  the  reduction  or  setting  of  the  frag- 
ments in  cases  of  fracture,  they  are  usually  retained  in 
position  until  union  occurs  by  the  use  of  splints  held  in 
position  by  means  of  bandages  or  strips  of  muslin.  Splints 
may  be  made  of  wood,  or  of  tin,  lead,  copper,  or  wire, 
binders'  board,  leather,  felt,  paper,  gutta-percha,  or  plaster- 
of-Paris. 

Wooden  Splints. — The  simplest  splints  are  made  from 
wood — white  pine,  willow,  or  poplar  being  the  best  mate- 
rial to  employ  for  their  construction,  being  sufficiently 
strong  to  give  fixation  to  the  parts  and  at  the  same  time 
being  light.     Splints  made  from  smooth  white  pine,  wil- 


342  FRACTURES. 

low,  or  poplar  boards  from  one-eighth  to  one-fourth  of  an 
inch  in  thickness  may  be  employed  in  the  form  of  straight 
or  angular  splints,  and  their  preparation  is  a  matter  of 
little  difficulty. 

Wooden  splints  before  being  applied  to  the  part  should 
be  well  padded  with  cotton-wool,  oakum,  or  hair;  and 
where  lateral  wooden  splints  are  employed  in  the  treat- 
ment of  fractures  of  the  lower  extremity,  it  is  usual  to 
place  bandages  or  junk  bags  between  the  limb  and  the 
splint.  The  carved  wooden  splints  which  are  sold  by  the 
instrument-makers  are  not  to  be  recommended,  as  a  rule, 
for  unless  the  surgeon  has  a  large  number  to  select  from,  it 
is  rare  that  a  splint  can  be  obtained  to  accurately  fit  any 
individual  case. 

Binders'  Board  Splints. — Binders'  board  is  an  excellent 
material  from  which  to  construct  splints ;  it  is  first  soaked 
in  boiling  water,  and  when  sufficiently  soft  is  padded  with 
cotton  or  a  layer  of  lint  and  moulded  to  the  part.  It  may 
be  secured  in  position  by  a  bandage ;  as  it  becomes  dry,  it 
hardens  and  retains  the  shape  into  which  it  was  moulded. 
Undressed  Leather  Splint.  —Undressed  leather  is  a  good 
material  from  which  to  construct  splints;  it  is  applied  by 
first  soaking  the  leather  in  boiling  water,  and  after  padding 
it  with  cotton  or  lint  it  is  moulded  to  the  part  and  re- 
tained in  position  by  a  bandage. 

Felt  Splints. — These  are  made  from  wool  saturated  with 
gum  shellac  and  pressed  into  sheets.  This  material  is  pre- 
pared for  application  to  the  surface  by  heating  it  before  a 
fire  until  it  becomes  pliable,  or  by  dipping  it  into  boiling 
water. 

Gutta-percha  Splints. — These  are  made  from  sheets  of 
this  material  from  one-sixteenth  to  one-fifth  of  an  inch  in 
thickness,  and  may  often  be  employed  with  advantage. 
The  splint  is  prepared  for  use  by  immersing  it  in  hot 
water ;  when  it  becomes  soft  it  can  be  moulded  to  the  sur- 
face. Care  should  be  taken  that  it  is  not  allowed  to  become 
too  soft  by  long  immersion,  as  it  then  cannot  be  conven- 
iently handled. 

Paper  Splints. — These  are  made  from  layers  of  Manila 


FRACTURE  DRESSINGS.  343 

paper  stiffened  with  starch,  and  constitute  a  very  fair 
substitute  for  some  of  the  varieties  of  splints  previously 
mentioned. 

Plaster-of-Paris,  Starch,  Chalk  and  Gum,  Silicate  of 
Potassium  or  Sodium  Splints. — These  may  be  employed  for 
the  construction  of  splints,  either  movable  or  immovable, 
in  the  treatment  of  fractures ;  their  method  of  prepara- 
tion and  application  are  described  on  page  93  et  seq. ;  the 
plaster-of- Paris  dressing  is  the 
one  which  is  most  generally  used  Fig.  246. 

at  the  present  time. 

Fracture-box. — This  is  a  form 
of  splint  used  in  the  treatment 
of  fractures  of  the  lower  ex- 
tremity, and  consists  of  a  board 

eighteen      to      twenty     inches     in         Fracture-box  with  movable 

length,  with  a  foot-board  firmly 

secured  at  its  lower  extremity ;  the  sides  are  secured  by 
hinges  which  allow  them  to  be  raised  or  lowered  (Fig. 
246).  A  fracture-box  of  greater  length  is  required  for 
the  treatment  of  fractures  about  the  knee-joint. 

Bran,  Sand,  or  Junk  Bags. — These  are  constructed  by 
taking  a  piece  of  unbleached  muslin  five  feet  in  length 
and  fourteen  and  one-half  inches  in  width,  doubling  it, 
and  securing  the  free  margins,  except  at  the  mouth,  by 
stitches  so  as  to  form  a  bag ;  the  bag  is  then  inverted  so 
that  the  edges  of  the  seams  are  brought  on  the  inner  sur- 
face of  the  bag.  The  bag  is  next  filled  with  dry  sand, 
bran,  hair,  or  straw,  and  the  mouth  of  the  bag  is  closed 
by  stitches  or  by  being  tied  with  a  string.  Bran  bags 
with  splints,  or  sand  bags,  are  frequently  employed  in  the 
treatment  of  fractures  of  the  femur. 

Bandages.— These  are  made  of  muslin,  and  are  used 
to  retain  splints  in  the  treatment  of  fractures,  and  are 
also  sometimes  applied  directly  to  the  injured  part  before 
the  application  of  splints  to  control  muscular  spasm  and 
limit  the  amount  of  swelling  ;  when  a  bandage  is  so  used, 
it  is  known  as  a  primary  roller.  The  use  of  the  primary 
roller  is  sometimes  of  the  greatest  service  in  the  dressing 


344 


FRACTURES. 


Fig.  247. 


Rack  for  supporting  bed- 
clothes in  fractures  of  the 
lower  extremity. 


of  fractures,  but  its  use  in  inexperienced  hands  has  so 
often  been  followed  by  unfortunate  results  in  the  early 
treatment  of  fractures,  or  in  cases  which  are  not  under 
constant  observation,  that  I  think  it  a  safe  rule  of  prac- 
tice to  discard  entirely  the  use  of  the  primary  roller. 

Compresses. — These  are  made  from  a  number  of  folds 
of  lint,  or  of  cotton  or  oakum,  and  are  often  employed  to 

retain  fragments  in  position  or  to 
make  localized  pressure  upon  cer- 
tain points  in  the  treatment  of 
fractures.  The  compresses  are 
held  in  position  by  strips  of  adhe- 
sive plaster,  by  a  few  turns  of  a 
roller-bandage,  or  by  the  splints. 
Compresses  are  sometimes  em- 
ployed to  protect  bony  promi- 
nences of  the  skeleton  from  the 
pressure  of  the  splints,  but  this  purpose  is  often  better 
effected  by  the  use  of  small  pieces  of  soap  plaster  spread 
on  chamois  skin  fitted  over  the  prominent  points. 

Rack  or  Cradle. — This  is  made  of  wire  or  wooden 
hoops,  and  is  often  employed  to  support  the  weight  of  the 
bedclothes  in  the  treatment  of  fractures  of  the  lower  ex- 
tremity (Fig.  247). 

Evaporating  Lotions  in  Fracture. — The  employment 
of  evaporating  lotions  such  as  lead-water  and  laudanum, 
or  muriate  of  ammonium  and  laudanum,  to  the  skin  in  the 
region  of  fractures  is  highly  recommended  by  many  sur- 
geons, especially  in  fractures  involving  or  situated  near 
joints.  They  are  here  employed  to  relieve  pain,  to  limit 
inflammatory  swelling,  and  to  hasten  absorption  of  the 
blood  and  serum  at  the  seat  of  fracture.  Many  surgeons, 
on  the  other  hand,  think  that  their  use  causes  irritation  of 
the  skin  and  delays  the  process  of  repair  in  the  union  of 
the  fracture,  and  strongly  condemn  their  employment. 
Personally,  I  have  never  seen  bad  results  from  their  use, 
and  have  generally  employed  them  in  fractures  near  or 
involving  the  joints  ;  but  I  do  not  consider  their  employ- 
ment essentia],  and  when  I  use  them  I  do  so  for  only  two 


SEPARATION  OF  THE  EPIPHYSES.  345 

or  three  days.  In  eases  of  fractures  accompanied  with 
much  pain  and  swelling,  when  the  surgeon  does  not  wish 
to  use  any  of  the  lotions  named,  an  ointment  of  ichthvol  1 
part,  lanoline  3  parts,  spread  on  lint  and  wrapped  around 
the  limb,  will  often  prove  a  satisfactory  dressing,  or  a 
layer  of  cotton  may  be  simply  wrapped  around  the  part 
before  the  application  of  the  splints. 

Massage  in  the  Treatment  of  Fracture. — Lucas- 
Championniere  advocates  and  practises  immediate  and 
continuous  massage  in  the  treatment  of  fractures,  and 
holds  that  by  its  use  pain  is  diminished,  repair  of  the  bone 
hastened  by  the  profuse  deposit  of  callus,  and  atrophy 
of  muscles  and  stiffening  of  joints  avoided. 

Massage  is  employed  as  soon  as  possible  after  the  fract- 
ure has  occurred,  and  consists  in  manipulations  with  the 
thumb,  the  lingers,  or  the  whole  hand.  The  limb  is  held 
by  an  assistant  and  extension  is  made,  or  it  is  placed  upon 
a  firm  pillow  or  a  sand  cushion.  The  manipulations  should 
be  made  in  the  direction  of  the  muscular  fibres  and  of 
the  blood-current,  and  firm  pressure  should  not  be  made 
directly  over  the  seat  of  fracture. 

Massage  should  be  practised  for  from  fifteen  to  twenty 
minutes  daily,  and  no  retention  apparatus  should  be  ap- 
plied in  the  intervals  unless  there  is  marked  tendency  to 
displacement  of  the  fragments,  when  some  form  of  reten- 
tion apparatus  or  splint  may  be  used.  These  manipula- 
tions should  be  continued  for  some  w7eeks,  until  union  is 
firm  at  the  seat  of  fracture.  Massage  has  also  been  com- 
bined with  the  ambulatory  method  of  treatment  of  fract- 
ures of  the  lower  extremity.  This  method  of  treating 
fractures  by  massage  may  be  said  to  be  still  on  trial,  suffi- 
cient experience  not  yet  having  accumulated  to  prove  that 
it  possesses  marked  advantage  over  the  generally  adopted 
method  of  treatment  by  immobilization. 

SEPARATION   OF    THE    EPIPHYSES. 

This  lesion  consists  in  a  separation  of  the  epiphysis  of 
the  bone  from  its  diaphysis. .   The  epiphyses  are  entirely 


346  FRACTURES. 

cartilaginous  in  infants,  but  ossification  occurs  later  at 
various  periods  for  different  bones.  The  separation  may 
occur  at  any  time  from  birth  up  to  the  twenty-first  year. 
The  age  at  which  traumatic  separation  of  the  epiphyses 
has  been  most  observed  is  from  the  twelfth  to  the  fifteenth 
year.     Epiphyseal  separations  may  be  simple  or  compound. 

Simple  Separations. — Traumatic  separations  of  the  epiph- 
yses may  result  from  direct  and  indirect  violence,  from 
traction  or  torsion,  and  in  rare  cases  from  muscular  action. 
The  injury  is  alway  accompanied  by  stripping  of  the  peri- 
osteum from  the  end  of  the  shaft  of  the  bone,  but  it  gen- 
erally remains  firmly  attached  to  the  epiphysis.  Separation 
of  the  epiphyses  in  children  results  from  the  application 
of  considerable  force;  according  to  Poland,  an  injury 
which  would  be  able  to  produce  a  dislocation  in  an  adult 
will  in  a  child  usually  result  in  a  separation  of  an  epiphy- 
sis. Separation  of  the  epiphyses  may  result  from  disease, 
as  in  tuberculous  and  syphilitic  ostitis  and  acute  infective 
ostitis.  Suppuration  in  the  region  of  an  epiphysis  may 
result  in  its  separation. 

Compound  separations  of  the  epiphyses  are  frequently 
met  with,  being  most  common  at  the  lower  epiphysis  of 
the  femur  and  the  upper  epiphysis  of  the  humerus. 
These  are  grave  injuries,  from  the  fact  that  infection  is 
apt  to  occur,  resulting  in  suppurative  osteomyelitis  and 
necrosis,  followed  by  arrest  of  growth  of  the  limb  and 
shortening. 

Symptoms. — These  are  mobility,  deformity,  crepitus, 
loss  of  function,  pain,  and  swelling.  Mobility,  which 
exists  at  a  point  where  it  should  not  be  observed,  is  a  most 
important  symptom,  and  is  most  marked  if  the  separa- 
tion of  the  periosteum  be  extensive.  Deformity  is  also 
more  marked  than  in  fractures,  the  smoothness  of  the 
separated  surfaces  permitting  of  displacement ;  this  varies 
with  the  amount  of  displacement  of  the  diaphysis  and  the 
amount  and  mode  of  application  of  the  force.  Crepitus 
is  soft  and  muffled  ;  loss  of  function  is  usually  marked  ; 
and  pain  and  swelling  at  the  seat  of  injury  are  soon  fol- 
lowed by  extravasation  of  blood. 


SEPARATION  OF  THE  EPIPHYSES.  347 

Diagnosis. — Separations  without  displacement  are  diffi- 
cult  to  diagnose,  and  are  often  considered  as  sprains  of 
joints.     In  infants  this  lesion  is  difficult  to  recognize,  and 

often  escapes  detection,  but  may  be  followed  in  a  few 
weeks  by  swelling,  suppuration,  and  symptoms  of  chronic 
osteomyelitis. 

Separation  of  the  epiphyses  is  most  apt  to  be  confounded 
with  fracture  or  dislocation  ;  the  diagnosis  is  made  from 
fracture  by  observing  the  line  of  separation,  shape  of  the 
displaced  epiphyseal  fragment,  the  deformity  (which  is 
very  characteristic  in  certain  separations),  and  the  soft 
character  of  the  crepitus.  From  dislocation,  the  diagnosis 
is  based  upon  the  following  signs  :  Dislocations  are  rare  in 
infants  and  children.  In  separations  of  the  epiphyses,  if 
the  displacement  is  reduced,  it  tends  to  recur  upon  re- 
moval of  the  force ;  while  in  dislocation,  if  reduction  is 
accomplished,  it  is  not  likely  to  recur  when  the  force  is 
removed.  Rigidity  is  present  in  dislocation,  while  preter- 
natural mobility  is  marked  in  epiphyseal  separation.  In 
many  joints  the  epiphysis  will  still  be  found  to  be  con- 
nected with  the  joint  and  to  retain  its  normal  relations 
with  the  surrounding  articular  structures.  In  compound 
separations  of  the  epiphyses  the  diagnosis  may  be  made 
by  observing  that  the  displaced  end  of  the  bone  is  not 
covered  by  articular  cartilage. 

Prognosis. — Union  of  the  separated  epiphyses  occurs  by 
the  same  process  as  that  of  a  fracture.  The  amount  of 
callus,  which  is  formed  largely  by  the  periosteum  uniting 
the  fragments,  varies  with  the  completeness  of  their  reduc- 
tion. Non-union  has  never  been  observed  in  this  injury. 
Ankylosis  of  the  neighboring  joint  may  result  in  spite  of 
the  greatest  care  in  the  reduction  of  the  deformity  and  in 
the  treatment,  yet  permanent  deformity  may  be  present 
and  interfere  very  little  with  the  function  of  the  limb. 
Arrest  of  growth  of  the  limb  after  this  injury  in  young 
subjects  may  be  observed,  but  is  not  a  necessary  result, 
for  the  epiphyseal  cartilage  may  perform  its  function  as 
completely  as  before  the  injury,  but  is  more  apt  to  occur 
if  the  separation  takes  place  between  the  epiphyses  and 


348  FRACTURES. 

the  epiphyseal  cartilage,  or  the  cartilage  itself  is  severely 
injured.  Arrest  of  growth  is  not  marked  in  many  cases, 
for  the  reason  that  the  injury  occurs  at  a  period  when  the 
growth  of  the  skeleton  is  almost  complete. 

Treatment. — This  consists  in  reduction  of  the  deform- 
ity, which  in  many  cases  is  difficult  unless  an  anaesthetic 
be  administered,  and  fixation  of  the  parts  after  reduction 
by  the  use  of  splints  and  bandages,  the  dressings  employed 
being  similar  to  those  used  in  fracture  at  a  corresponding 
portion  of  the  bone.  Muscular  wasting  should  be  pre- 
vented by  the  early  employment  of  massage.  Compound 
separations  of  the  epiphyses  are  treated  in  the  same 
manner  as  compound  fractures,  great  care  being  taken  to 
render  the  wound  aseptic  and  to  maintain  it  in  this  condi- 
tion. 

DRESSING  OF  SPECIAL  FRACTURES. 

Fracture  of  the  Nasal  Bones. — Fractures  of  the  nasal 
bones  are  often  accompanied  with  fractures  involving  the 
septum,  the  nasal  process  of  the  maxillary  bone,  and  the 
nasal  spine  of  the  frontal  bone. 

Treatment. — This  consists  in  replacing  the  fragments,  if 
displacement  exists,  by  manipulation  with  the  fingers  over 
the  seat  of  fracture  and  by  pressure  made  from  within  the 
nostrils  by  a  probe  or  a  steel  director.  When  the  displace- 
ment is  once  corrected,  it  is  not  apt  to  recur,  and  in  the 
majority  of  cases  no  dressing  is  required.  Before  resort- 
ing to  any  manipulation  within  the  nasal  cavities  the  mu- 
cous membrane  should  be  thoroughly  cocainized  to  render 
the  operation  painless.  When  there  is  a  return  of  the  de- 
pression of  the  fragments  or  displacement  of  the  septum 
after  correcting  the  deformity  by  raising  the  depressed 
fragment,  or  bending  the  septum  into  place  with  a  director, 
the  parts  may  be  held  in  position  by  packing  the  nasal 
cavity  firmly  with  a  strip  of  antiseptic  gauze  or  by  the  use 
of  Asch's  tubes. 

In  lateral  displacements  of  the  nasal  bones  from  fract- 
ure, after  reducing   the   displacement   a    small   compress 


FRACTURES  OF  MALAR  BONE  AND  ZYGOMA.      349 

held  over  the  fragment  by  strips  of  adhesive  plaster  will 
be  the  only  dressing  required. 

Mason  transfixes  the  nose,  after  reduction  of  the  frag- 
ments, with  a  stout  needle,  and  steadies  the  pieces  with  a 
strip  of  plaster  crossing  the  bridge  of  the  nose  and  fast- 
ened to  the  ends  of  the  needle.  The  needle  is  kept  in 
position  for  eight  or  ten  days  (Fig.  248). 

Fig.  248. 


Mason's  dressing  for  fracture  of  the  nasal  bones. 

Profuse  hemorrhage  sometimes  occurs  after  fracture  of 
the  nasal  bones,  and  may  require  plugging  of  the  nares  to 
control  it.  Fractures  of  the  nasal  bones  are  usually  quite 
firmly  united  in  two  weeks,  and  dressings  may  be  dis- 
pensed with  after  this  time. 

Fractures  of  the  Malar  Bone  and  Zygoma.— These 
fractures  are  usually  the  result  of  direct  force ;  the  dis- 
placement is  upward  or  backward,  and  when  the  zygo- 
matic arch  is  broken  the  fragments  from  pressure  upon 
the   masseter    muscle    or  on  the  tendon  of  the  temporal 


350  FRACTURES. 

muscle  may  interfere  with  the  movements  of  the  lower 
jaw  in  mastication.  This  displacement  is  corrected  by 
cutting  down  upon  the  fragment  and  elevating  it  or  by 
passing  a  tenaculum  into  the  fragment  and  raising  it. 
Outward  displacements  may  be  corrected  by  pressure  and 
the  application  of  a  compress. 

Treatment. — The  dressing  of  these  fractures  after  the 
correction  of  the  deformity  consists  in  the  application  of 
a  compress  of  lint  over  the  seat  of  fracture,  held  in  posi- 
tion by  strips  of  adhesive  plaster  or  a  bandage.  There  is 
little  tendency  to  recurrence  of  the  deformity  after  it  has 
been  corrected,  and  union  at  the  seat  of  fracture  is  usually 
firm  at  the  end  of  three  weeks. 

Fractures  of  the  Upper  Jaw. — These  fractures  may 
involve  the  body,  the  nasal  processes,  or  the  alveolar  proc- 
esses. 

Treatment. — The  deformity  should  be  corrected,  and  if 
any  teeth  have  been  displaced  they  should  be  replaced ; 
if  there  is  comminution  of  the  alveolus,  the  teeth  in  the 

Fig.  249. 


Dressing  for  fracture  of  the  upper  jaw. 


separate  fragments  may  be  fastened  together  by  fine  wire 
to  fix  the  fragments  and  hold  them  in  place ;  the  teeth 
of  the  lower  jaw  should  be  brought  up  in  contact  with 


FRACTURES  OF  THE  LOWER  JAW.  351 

those  of  the  upper  jaw,  and  the  jaws  should  be  secured 
together  by  the  application  of  a  Barton's  or  a  Gibson's 
bandage  (T^ig.  249).  Interdental  splints,  made  of  cork, 
with  grooves  to  fit  the  teeth,  or  of  gutta-percha,  are  also 
employed  in  the  dressing  of  these  fractures.  The  patient 
should  not  be  allowed  to  move  the  jaw  in  mastication,  and 
should  be  nourished  by  liquid  and  semisolid  food,  which 
may  be  taken  without  removing  any  teeth  to  give  space 
for  its  introduction.  The  bandage  should  be  removed 
every  second  or  third  day,  and  it  should  be  reapplied  in 
the  same  manner.  Union  is  usually  firm  at  the  end  of 
four  or  five  weeks,  and  dressings  may  be  dispensed  with 
at  this  time. 

Fractures  of  the  Lower  Jaw. — The  lower  jaw  may  be 
broken  at  or  near  the  symphysis,  the  most  usual  seat  of 
fracture  being  near  the  mental  foramen  ;  it  is  often  broken 
at  two  places  at  once,  and  the  fractures  are  in  many  cases 

Fig.  250. 


Dressing  for  fracture  of  the  lower  jaw. 


rendered  compound  by  laceration  of  the  mucous  mem- 
brane, or  the  injury  may  consist  in  a  separation  of  a  por- 
tion of  the  alveolar  process  of  the  bone. 

Treatment. — The    dressing  of  a  fracture  of  the  lower 


352  FRACTURES. 

jaw,  after  reducing  the  displacement  and  replacing  any 
loosened  or  detached  teeth,  consists  in  applying  a  pad  of 
lint  under  the  chin  and  bringing  the  jaw  up  against  the 
upper  jaw,  holding  the  compress  in  place,  and  securing  the 
jaws  firmly  in  contact  by  applying  a  Barton's  (Fig.  250), 
modified  Barton's,  or  Gibson's  bandage.  The  bandage 
should  be  removed  and  reapplied  at  the  end  of  the  second 
or  third  day,  and  at  like  intervals  during  the  course  of 
treatment.  The  patient  should  be  fed  upon  a  liquid  or 
semisolid  diet,  not  being  allowed  to  chew  solid  food  until 
union  at  the  seat  of  fracture  has  become  firm.  A  very 
satisfactory  temporary  dressing  for  a  fracture  of  the  lower 
jaw  consists  in  the  application  of  a  four-tailed  sling. 

Some  surgeons  prefer  to  use  an  external  splint  moulded 
from  pasteboard  or  gutta-percha  fitted  to  the  chin  in  the 
dressing  of  this  fracture  (Figs.  251  and  252),  this  being 

Fig.  251.  Fig.  252. 


Shape  of  splint  before  being  fitted  to  chin.  Splint  moulded  to  fit 

(Roberts.)  chin.    (Roberts.; 

padded  with  cotton  and  held  in  place  by  a  Barton's  or 
Gibson's  bandage.  Where  there  is  much  difficulty  in 
keeping  the  fragments  in  position  wiring  together  of  the 
teeth  may  be  employed,  or  the  fragments  may  be  perfor- 
ated with  a  drill  and  held  in  place  by  a  strong  silver  wire 
suture ;  interdental  splints  of  metal  or  gutta-percha  are 
also  sometimes  used  for  this  purpose.  During  the  course 
of  treatment  of  fracture  of  the  jaws  the  mouth  often  be- 
comes very  offensive  from  fermentation  of  the  saliva  and 
discharges,  and  it  is  well  to  use  frequently  a  mouth-wash 
of  chlorate  of  potassium  and  tincture  of  myrrh,  or  boric 
acid  solution. 


FRACTURES  OF  THE  RIBS.  353 

The  dressings  for  fracture  of  the  lower  jaw  are  applied 
for  four  or  six  weeks,  the  union  usually  being  quite  firm 
at  the  end  of  this  time. 

Fracture  of  the  Hyoid  Bone. — In  fracture  of  the 
hyoid  bone,  if  displacement  exists,  its  reduction  is  facili- 
tated by  pressure  made  with  the  finger  in  the  pharynx. 

Treatment. — This  consists  in  enforced  quiet  and  the  use 
of  opium  if  cough  is  a  prominent  symptom,  and  the 
inflammatory  symptoms  may  require  the  employment  of 
active  local  treatment.  A  dressing  may  sometimes  be  em- 
ployed with  advantage,  consisting  of  a  splint  of  pasteboard 
or  leather  moulded  to  the  anterior  portion  of  the  neck. 

Fractures  of  the  Larynx  or  Trachea. — In  fractures 
of  the  larynx  or  trachea  where  there  is  little  displace- 
ment and  dyspnoea  is  not  marked,  the  parts  should  be 
supported  by  the  application  of  compresses  of  lint  held 
in  place  by  strips  of  adhesive  plaster.  If,  on  the  other 
hand,  the  respiration  is  embarrassed  or  there  is  free  expec- 
toration of  blood,  tracheotomy  should  be  performed,  and 
if  the  injury  be  seated  in  the  larynx  the  displacement  of 
the  fragments  may  be  overcome  by  manipulation  with  the 
ringer  or  a  director  through  the  tracheal  wound,  or  the 
larynx  may  be  packed  with  a  strip  of  antiseptic  gauze  to 
control  hemorrhage  or  hold  the  fragments  in  position,  the 
patient  in  the  meantime  breathing  through  a  tracheotomy- 
tube  secured  in  the  tracheal  wound;  the  packing  should 
be  removed  in  a  few  days,  the  tracheotomy-tube  being 
permanently  removed  as  soon  as  the  patient  can  breathe 
comfortably  through  the  larynx  with  the  tracheal  wound 
closed.  In  fracture  of  the  trachea  the  opening  into  the 
trachea  should  be  below  or  at  the  seat  of  injury. 

Fractures  of  the  Ribs. — Fractures  of  the  ribs  are 
more  frequent  than  fractures  of  any  other  bones  of  the 
trunk;  the  ribs  most  commonly  broken  are  those  from  the 
fourth  to  the  tenth ;  the  most  common  seat  of  fracture  is 
near  the  anterior  or  posterior  portion  ;  the  displacement  is 
usually  not  marked,  unless  a  number  of  ribs  be  broken, 
being  prevented  by  the  intercostal  muscles  and  aponeuroses. 

Treatment.— The  dressing  of   fractures  of  the  ribs  is 

23 


354 


FRACTURES. 


Fig.  253. 


best  accomplished  by  enveloping  the  side  of  the  chest  on 
which  the  rib  or  ribs  are  broken  with  broad  straps  of 
adhesive  or  rubber  plaster.  The  adhesive  straps  should 
be  two  and  a  half  inches  in  width  and  sufficiently  long  to 
extend  from  the  spine  to  the  middle  of  the  sternum.  The 
straps  are  warmed,  and  the  first  strap  is  firmly  applied  at 
the  base  of  the  chest,  extending  from  the  spine  to  the 
mid-sternal  line;  a  number  of  ascending  straps  are  applied 
in  this  way,  each  strap  overlapping  the  preceding  one  by 
about  one-third  of  its  width  until  half  the  chest  is  covered 
in   (Fig.  253).     This  dressing  usually  gives  the  patient 

much  comfort,  and  the  straps  need 
not  be  renewed  until  they  become 
slightly  loosened,  usually  at  the 
end  of  a  week  or  ten  days  ;  they 
should  then  be  renewed  in  the 
same  manner.  The  dressings  are 
usually  dispensed  with  at  the  end 
of  three  or  four  weeks,  as  repair 
of  the  fracture  is  generally  well 
advanced  at  this  time. 

A  satisfactory  temporary  dress- 
ing consists  in  surrounding  the 
chest  by  a  broad  binder  of  stout 
linen  or  muslin ;  indeed,  some  sur- 
geons prefer  to  employ  this  dressing  during  the  course  of 
treatment,  but,  as  a  rule,  I  think  it  is  not  as  good  a  dress- 
ing as  the  adhesive  plaster  dressing,  as  the  former  con- 
fines the  movements  of  both  sides  of  the  chest. 

Fractures  of  the  Costal  Cartilages. — These  fractures 
often  take  place  at  the  junction  of  the  cartilages  with  the 
ribs  or  in  the  body  of  the  cartilages,  and  the  union  of  the 
fracture  usually  takes  place  by  the  production  of  a  mass 
of  bone  at  the  seat  of  fracture. 

Treatment. — It  consists  in  the  application  of  strips  of 
adhesive  plaster  applied  in  the  same  manner  as  for  fract- 
ure of  the  ribs,  and  the  dressings  should  be  retained  for 
about  the  same  time. 

Fractures  of  the  Sternum. — Fractures  of  the  sternum 


Adhesive  plaster  dressing 
for  fracture  of  the  ribs. 
(Hamilton.) 


FRACTURES  OF  THE  PELVIS. 


355 


Fig.  254. 


are  rare  injuries,  but  diastasis  of  the  bones  of  the  sternum 
is  a  more  common  accident. 

Treatment. — The  treatment  for  both  fracture  and  dias- 
tasis is  the  same,  and  consists  in  the  application  of  a  com- 
press over  the  seat  of  fracture  held  in  place  by  a  broad 
bandage,  or,  better,  by  strips  of  adhesive  plaster  (Fig. 
254),  applied  so  as  to  cover  and  fix  the  anterior  portion 
of  the  chest,  covering  the 
entire  length  of  the  ster- 
num. This  dressing  should 
be  retained  for  at  least  four 
weeks,  being  renewed  if  it 
becomes  loose  at  the  end 
of  a  week  or  ten  days. 

Fractures  of  the  Pelvis. 
— These  fractures  may  in- 
volve the  ilium,  ischium, 
pubis,  or  sacrum.  Vertical 
fractures  either  single  or 
double,  and  separations  of 
the  pelvic  bones  from  their 
junctions  may  also  occur,  and  are  often  serious  injuries 
from  implication  of  the  pelvic  viscera. 

Treatment. — The  reduction  of  the  displacement  should 
be  first  accomplished  as  far  as  possible  by  external  manip- 
ulation, together  with  internal  manipulation  by  the  fingers 
introduced  into  the  rectum,  or  into  the  vagina  in  the 
female.  The  patient  should  be  placed  upon  a  firm  bed 
on  his  back,  with  the  knees  slightly  flexed  over  a  pillow, 
and  the  parts  should  be  kept  at  rest  by  surrounding  the 
pelvis  with  broad  straps  of  adhesive  plaster  or  a  stout 
muslin  binder,  or  by  a  firmly  applied  padded  pelvic  belt. 
The  hip-joints  should  be  kept  at  rest  by  the  application 
of  pasteboard  splints  or  by  sand  bags.  The  dressings 
should  be  retained  for  a  period  of  at  least  six  weeks. 

When  these  fractures  are  complicated  by  injury  of  the 
pelvic  viscera  various  operative  procedures  may  be  re- 
quired, which  will  compel  the  surgeon  to  modify  the 
method  of  dressing. 


Adhesive  plaster  dressing  for  fracture 
of  the  sternum. 


356  FRACTURES. 

Fractures  of  the  Sacrum  and  Coccyx. — The  dressing 
of  fractures  of  the  sacrum,  after  effecting  reduction  of  the 
fragments  as  far  as  possible  by  pressure  from  within  the 
rectum,  consists  in  the  application  of  broad  adhesive  straps 
around  the  pelvis,  the  patient  at  the  same  time  being  kept 
at  rest  in  bed. 

When  the  coccyx  is  fractured,  after  reduction  of  the  dis- 
placement, which  may  sometimes  be  accomplished  by 
manipulation  with  the  finger  in  the  rectum,  the  patient 
should  be  confined  to  bed  and  the  bowels  kept  at  rest  by 
the  use  of  opium  by  suppository.  The  patient  should 
remain  in  bed  for  two  or  three  weeks. 

Fractures  of  the  Vertebrae. — Fractures  of  the  verte- 
bras are  always  most  serious  injuries,  not  only  from  the 
damage  to  the  bones  themselves,  but  also  from  that  to  the 
spinal  cord,  membranes,  and  nerves,  which  often  accom- 
panies them.  In  transporting  or  turning  in  bed  a  patient 
suffering  from  fracture  of  the  vertebrae,  great  care  should 
be  exercised,  for  rough  or  sudden  motions  may  cause  a 
displacement  of  the  fragments  which  might,  by  injury  of, 
or  pressure  upon,  the  spinal  cord,  rapidly  prove  fatal. 

Treatment. — If  the  deformity  is  marked,  efforts  should 
be  made  to  reduce  it  by  extension  and  counter-extension  ; 
and  the  result  may  be  successful,  especially  if  the  fracture 
be  associated  with  a  dislocation  of  the  vertebras.  In  some 
cases  the  use  of  permanent  extension  by  means  of  weights 
attached  to  the  legs,  shoulders,  and  chest  by  adhesive 
plaster  and  bandages,  has  been  successful  in  reducing  the 
deformity.    Laminectomy  may  be  practised  in  certain  cases. 

The  patient  should  be  placed  upon  his  back  upon  a  bed 
with  a  hair  mattress,  or  better,  if  it  can  be  obtained,  a 
water-bed,  which  consists  of  a  rubber  mattress  filled  with 
water,  which  distributes  the  weight  of  the  patient's  body 
evenly  over  the  surface.  Whatever  form  of  bed  be  used, 
the  greatest  care  should  be  exercised  to  keep  the  patient 
absolutely  clean,  and  the  parts  of  the  body  or  limbs  which 
are  exposed  to  pressure  should  be  frequently  bathed  with 
alcohol  or  soap  liniment ;  and  to  distribute  the  pressure, 
small  pads  should  be  placed  under  the  parts  and  changed 


FRACTURE  OF  THE  SKULL.  357 

at  intervals.  These  precautions  are  necessary  to  prevent, 
if  possible,  the  formation  of  extensive  bedsores,  which  are 
a  frequent  and  troublesome  complication  of  these  injuries. 

The  boioels  should  be  carefully  watched,  and,  if  consti- 
pation is  present,  it  should  be  relieved  by  the  use  of  ene- 
mata  ;  and,  as  it  is  not  desirable  to  lift  the  patient  to  slip 
a  bed-pan  under  him,  the  discharges  may  be  received  in  a 
flat  tin  plate  pushed  under  the  thighs  and  buttocks,  or  on 
pads  of  oakum  or  old  muslin. 

The  care  of  the  bladder  is  also  a  matter  of  the  greatest 
importance ;  the  retention  which  at  first  exists  should  be 
relieved  by  the  use  of  a  flexible  catheter  carefully  steril- 
ized and  introduced  with  great  gentleness,  and  when  incon- 
tinence supervenes  a  catheter  which  has  been  thoroughly 
sterilized  should  also  be  used  at  intervals ;  the  employ- 
ment of  a  soft  instrument,  if  used  with  care,  is  not  apt 
to  produce  injury  to  the  urethra  or  bladder. 

The  employment  of  a  plaster-of-Paris  jacket  has  been 
followed,  in  some  cases,  by  good  results,  and  it  may  be 
applied  early  in  the  case,  or  after  the  patient  has  been 
kept  in  the  recumbent  posture  for  some  weeks  ;  by  its 
use  it  is  often  possible  to  get  the  patient  out  of  bed  and 
allow  him  to  sit  in  a  chair. 

In  fractures  involving  the  cervical  vertebrce,  care  should 
be  exercised  in  lifting  or  moving  the  head ;  it  is  often  of 
advantage  in  these  cases  to  apply  short  sand  bags  to  the 
sides  of  the  neck  and  head,  to  give  additional  fixation  to 
the  parts  while  the  patient  is  in  the  recumbent  posture,  or, 
if  he  is  allowed  to  get  out  of  bed,  to  apply  a  moulded 
leather  or  pasteboard  splint  to  the  neck,  shoulders,  and 
back  of  the  head,  for  the  same  purpose. 

The  course  of  treatment  in  cases  of  fractures  of  the  ver- 
tebrae, if  the  patient  does  not  succumb  to  the  injury  in  a 
few  days  or  weeks,  often  extends  over  many  months,  and 
recovery  is  often  more  or  less  incomplete  as  regards  the 
function  of  the  parts  below  the  seat  of  fracture. 

Fracture  of  the  Skull. — Treatment. — This  depends 
largely  upon  the  nature  of  the  injury — whether  simple 
or  compound — and  the  condition  of  the  cranial  contents. 


358  FRACTURES. 

In  simple  fractures  unaccompanied  with  cerebral  symp- 
toms no  special  dressing  is  required,  but  in  compound 
fractures  where  loose  fragments  are  present,  these  should 
be  removed ;  and  if  there  is  no  depression  of  the  frag- 
ments, and  if  no  cerebral  symptoms  are  present,  the 
wound  should  be  drained,  carefully  closed  and  dressed 
antiseptically,  the  dressings  being  held  in  place  by  a  recur- 
rent bandage  of  the  head.  The  patient  should  be  put  to 
bed,  and  the  use  of  an  ice-cap  to  the  head  is  often  of  ser- 
vice. The  diet  should  be  restricted,  while  calomel  and 
opium  or  bromide  of  potassium  should  be  administered  ; 
it  is  well  to  keep  the  patient  for  a  few  weeks  in  a  quiet 
and  darkened  room.  Where  cerebral  symptoms  are  pres- 
ent, either  in  simple  or  compound  fractures,  and  trephin- 
ing is  resorted  to,  the  dressing  of  the  wound  is  similar, 
and  the  same  general  treatment  should  be  adopted.  In 
all  cases  of  fracture  of  the  skull,  whether  subjected  to 
operative  treatment  or  not,  it  is  well  to  keep  the  patient 
at  rest  in  bed  for  three  or  four  weeks,  and  he  should  be 
cautioned  to  avoid  excesses  afterward,  and  should  not  re- 
sume active  work  for  some  months. 

Fractures  of  the  Clavicle. — Fractures  of  the  clavicle 
may  be  complete  or  incomplete,  and  in  the  latter  variety 
of  injury  the  deformity  is  not  usually  very  marked.  The 
indications  for  treatment  in  complete  fractures  of  the  clav- 
icle are  to  relax  the  sterno-cleido-mastoid  muscle,  to  pre- 
vent the  weight  of  the  arm  on  the  injured  side  from 
dragging  down  the  outer  fragment  of  the  clavicle,  and,  by 
fixing  the  scapula,  to  carry  the  attached  external  frag- 
ment outward  and  forward.  A  large  variety  of  dressings 
have  been  devised  and  used  to  accomplish  these  objects. 

Dressing  by  Position. — The  treatment  of  fractures  of  the 
clavicle  by  position  is  accomplished  by  placing  the  patient 
in  bed  on  his  back  upon  a  firm  mattress  with  a  low  pillow 
under  his  head,  and  the  arm  on  the  side  of  injury  should 
be  fastened  to  the  side  of  the  chest  by  a  few  circular  turns 
of  a  bandage  passing  around  the  arm  and  chest;  the  de- 
formity is  usually  very  satisfactorily  reduced  upon  the 
patient  assuming  this  position,  and  after  three  weeks'  rest 


FRACTURES  OF  THE  CLAVICLE. 


359 


in  this  position  the  union  is  generally  sufficiently  firm  to 
allow  the  patient  to  get  out  of  bed  and  be  about  with  the 
arm  bound  to  the  side  or  carried  in  a  sling  or  with  a  Yel- 
peau  bandage  applied,  without  any  recurrence  of  the 
deformity. 

Temporary  Dressing. — A  satisfactory  temporary  dressing 
for  fractures  of  the  clavicle  consists  in  the  application  of 
a  four-tailed  bandage ;  the  bandage  is  made  from  a  piece 
of  muslin  two  yards  in  length  and  fourteen  inches  in 
width  ;  a  hole  is  cut  in  its  centre  about  four  inches  from 
its  margin,  to  receive  the  point  of  the  elbow;  the  bandage 


Fig.  2-35. 


Four-tailed  bandage  for  fracture  of    Posterior  figure-of-eight  dressing  for  fract- 
the  clavicle.    (Stimsox.)  ure  of  the  clavicle.    (Hamilton.) 

is  then  split  into  four  tails  in  the  line  of  the  hole  and  to 
within  six  inches  of  it ;  the  body  of  the  bandage  should 
be  applied  so  that  the  point  of  the  elbow  rests  in  the  hole, 
and  a  folded  towel  being  placed  in  the  axilla,  the  lower 
tails  should  be  carried,  one  anteriorly,  the  other  poste- 
riorly, diagonally  across  the  chest  and  back,  to  the  neck  on 
the  side  opposite  the  seat  of  fracture,  and  secured  ;  the 
remaining  tails  are  next  carried  around  the  lower  part  of 


360 


FBACTURES. 


the  chest  and  secured  so  as  to  fix  the  arm  to  the  side  of 
the  body  (Fig.  255). 

In  some  cases  the  deformity  is  corrected  by  the  applica- 
tion of  a  posterior  figure-of-eight  bandage,  the  forearm  on 
the  side  of  injury  being  carried  in  a  sling  (Fig.  256). 

Sayre's  Dressing. — This  consists  of  two  strips  of  adhesive 
plaster  three  and  a  half  inches  wide  and  two  yards  in 
length.  The  first  strip  is  looped  around  the  arm  just 
below  the  axillary  margin,  and  is  pinned  or  sewed  with 


Ftg.  257. 


Fig.  258. 


Sayre's  dressing  for  fracture  of  the 
clavicle.    First  strip  applied. 


Sayre's  dressing  for  fracture  of  the 
clavicle.    Second  strip  applied. 


the  loop  sufficiently  open  not  to  constrict  the  arm.  The 
arm  is  then  drawn  downward  and  backward  until  the 
clavicular  portion  of  the  pectoralis  major  muscle  is  put 
sufficiently  upon  the  stretch  to  overcome  the  action  of  the 
sterno-cleido-mastoid  muscle,  and  in  this  way  draws  the 
sternal  fragment  of  the  clavicle  down  to  its  place.  The 
strip  of  plaster  is  then  carried  completely  around  the  body 


FRACTURES  OF  THE  CLAVICLE 


361 


and  pinned  or  stitched  to  itself  on  the  back  (Fig.  257). 
The  second  strip  is  next  applied,  commencing  upon  tin- 
front  of  the  shoulder  of  the  sound  side  ;  thence  it  is  carried 
over  the  top  of  the  shoulder  diagonally  across  the  hack, 
under  the  elbow,  diagonally  across  the  front  of  the  chest 
to  the  point  of  starting,  where  it  is  secured  by  pinning  or 
sewing.  A  slit  is  made  in  this  strip  to  receive  the  point 
of  the  elbow.  Before  the  elbow  is  secured  by  the  plaster 
it  should  be  pressed  well  forward  and  inward  (Fig.  258). 

Velpeau's  Dressing. — This  may  also  be  used  in  the 
treatment  of  fractures  of  the  clavicle  (Fig.  260).  A  com- 
press may  also  be  secured  by  the  vertical  turns  of  this 
bandage  over  the  seat  of  fracture  if  needed.  The  appli- 
cation of  the  bandage  is  described  on  page  62. 

In  any  form  of  dressing  in  which  the  arm  is  held 
against  the  side  of  the  chest  it  is  well  to  apply  a  folded 
towel  or  piece  of  lint  between  the  arm  and  chest  to  pre- 
vent the  skin  surfaces  from  becoming  excoriated. 

Fig.  259. 


Modified  Velpeau  dressing  for  fracture  of  the  right  clavicle. 

Modified  Velpeau's  Dressing.— A  modified  form  of  Vel- 
peau's dressing  for  fracture  of  the  clavicle  is  applied  as 


362  FRACTURES. 

follows  :  A  soft  towel  or  piece  of  lint  is  placed  against 
the  side  of  the  body  and  over  the  front  of  the  chest,  and 
held  in  position  by  a  strip  of  adhesive  plaster;  the  arm 
is  next  placed  in  the  Velpean  position,  a  good-sized  pad 
of  lint  is  next  applied  over  the  scapula,  and  this  is  held 
in  place  by  a  strip  of  adhesive  plaster  two  and  a  half 
inches  in  width  and  one  and  a  half  yards  in  length  ;  this 

Fig.  260. 


Velpeau  dressing  for  fracture  of  the  clavicle. 

strip  is  continued  downward  and  forward  so  as  to  pass 
over  the  po'nt  of  the  elbow,  and  is  carried  diagonally 
across  the  chest  to  the  shoulder  of  the  opposite  side,  and 
is  secured,  a  slit  being  cut  in  it  to  receive  the  point  of 
the  elbow;  a  compress  of  lint  is  next  placed  over  the  seat 
of  fracture  and  held  in  place  by  a  strip  of  adhesive  plas- 
ter; an  additional  strip  of  plaster  is  next  carried  from  the 


FRACTURES   OF  THE  CLAVICLE  LN  CHILDREN.    363 

spine  around  the  arm  and  chest  and  secured  on  the  oppo- 
site side  of  the  chest;  circular  turns  of  a  roller-bandage 
arc  then  passed  around  the  chest,  including  the  arm  from 
below  upward  until  the  arm  is  securely  fixed  to  the  body, 
and  the  dressing  is  finished  by  making  one  or  two  turns 
of  the  third  roller  of  Desault  (Fig.  259).  Or  the  turns 
of  the  third  roller  of  Desault  may  be  applied  first,  and 
the  dressing  may  be  finished  by  circular  turns  of  a  roller 
passing  around  the  arm  and  chest,  extending  from  the 
elbow  to  the  shoulder. 

The  removal  of  dressings  and  their  reapplication  will 
depend  upon  the  comfort  of  the  patient  and  the  manner 
in  which  they  keep  their  position.  As  a  rule,  in  fractures 
of  the  clavicle  the  dressings  are  removed  at  the  end  of 
the  second  or  third  day,  the  parts  are  inspected,  and  the 
skin  is  sponged  with  dilute  alcohol;  the  dressings  are 
then  reapplied,  and  if  the  patient  is  comfortable  and  the 
parts  are  in  good  position,  the  dressings  are  made  at  less 
frequent  intervals  until  union  is  completed  at  the  seat  of 

fracture. 

Union  in  cases  of  fracture  of  the  clavicle  is  generally 
quite  firm  at  the  end  of  four  or  five  weeks,  and  at  this 
time  the  dressings  may  be  removed,  and  the  patient 
should  carry  the  arm  of  the  affected  side  in  a  sling  for 
several  weeks,  and  should  not  undertake  any  work  requir- 
ing forcible  movements  of  the  arm  until  eight  or  ten 
weeks  have  elapsed  from  the  receipt  of  the  injury. 

Fractures  of  the  Clavicle  in  Children.— In  the  treat- 
ment of  fractures  of  the  clavicle  in  children  the  Velpeau 
or  modified  Velpeau  dressing  will  be  found  to  be  the  most 
satisfactory  dressing  to  employ  ;  and  as  these  patients  are 
particularly  apt  to  "disarrange  the  dressings,  it  is  well  to 
render  them  additionally  secure  by  applying  a  few  broad 
strips  of  adhesive  plaster  over  the  turns  of  the  roller-band- 
age, the  strips  following  the  turns  of  the  bandage. 
&The  time  required  for  union  in  fractures  of  the  clavicle 
in  children  is  somewhat  shorter  than  in  adults ;  the  dress- 
ings may  be  removed  at  the  end  of  three  weeks. 

Fractures  of  the  Scapula.— Fractures  of  the  scapula 


364 


FRACTURES. 


may  involve  the  body,  neck,  acromion,  or  coracoid  process 
of  the  bone.  Fractures  of  this  bone  are  rare,  those  of 
the  acromion  process  being  most  common. 

Fracture  of  the  Body  of  the  Scapula. — Treatment. — If 
deformity  is  present,  it  is  reduced  by  manipulation,  and 
compresses  of  lint  are  placed  above  and  below  the  seat 
of  fracture  and  held  in  place  by  adhesive  strips ;  the  arm 
is  next  fixed  to  the  side  of  the  body  by  spiral  turns  of  a 
roller-bandage  passing  around  the  arm  and  chest,  and  the 
forearm  is  supported  in  a  sling. 

Fracture  of  the  Neck,  Acromion,  or  Coracoid  Process  of 
the  Scapula. — Treatment. — The  treatment  of  these  fract- 
ures consists  in  placing  a  pad  of  lint  or  a  folded  towel 
in  the  axilla  and  binding  the  arm  to  the  body  by  spiral 
turns  of  a  roller-bandage  passing  around  the  arm  and 
chest,  and  supporting  the  forearm  in  a  sling.  These  fract- 
ures may  also  be  dressed  by  first  placing  a  pad  of  lint  or 
a  folded  towel  in  the  axilla  and  then  securing  the  arm  in 
the  Yelpeau  position  by  the  application  of  a  Yelpeau 
bandage  (Fig.  260).  In  fractures  of  the  acromion  or 
coracoid  processes  the  union  is  usually  fibrous.  In  the 
treatment  of  fractures  of  the  scapula  the 
dressing  should  be  retained  for  about  four 
weeks. 

Fractures  of  the  Humerus. — Fractures 
of  the  humerus  may  involve  the  upper  ex- 
tremity, the  shaft,  or  the  lower  extremity  of 
the  bone. 

Fractures  of  the  Upper  Extremity  of  the 
Humerus. — These  include  fractures  of  the 
head  and  anatomical  neck  of  the  bone, 
fractures  through  the  tuberosities,  fractures 
through  the  surgical  neck  of  the  humerus, 
and  separation  of  the  upper  epiphysis  of  the 
humerus. 
Moulded  splint  for       Treatment. — The  most  satisfactory  dress- 

shoulder  and  arm.  „  ,,    „        .  r    . ,        -,  i 

ing  for  all  fractures  of  the  humerus  above 
the  upper  third  of  the  bone  is  applied  as  follows:  A 
primary  roller  should  be  evenly  applied  from  the  tips  of 


Fig.  261. 


FRACTURES  OF  THE  HUMERUS. 


365 


the  fingers  to  the  seat  of  the  fracture,  the  arm  being  flexed 
at  the  elbow  before  the  bandage  is  carried  above  this 
point,  to  prevent  the  dangerous  constriction  which  might 
result  if  the  bandage  were  applied  with  the  arm  in  the 
straight  position,  and  it  were  afterward  flexed  at  the 
elbow.  A  folded  towel  or  a  thin  pad  of  lint  should  next 
be  placed  in  the  axilla  and  over  the  outer  surface  of  the 
chest,  to  furnish  a  firm  basis  of  support  for  the  humerus, 
and  also  to  prevent  excoriation  from  the  contact  of  the 
skin  surfaces.  A  splint  of  pasteboard,  felt,  or  leather 
(Fig.  261)  is  next  moulded  to  the  shoulder  and  arm  ; 
this  should  be  long  enough  to  extend  some  distance  below 

Fig.  262. 


Dressing  for  fracture  of  the  upper  extremity  of  the  humerus. 


the  seat  of  fracture  and  wide  enough  to  cover  in  about 
one-half  of  the  circumference  of  the  arm,  and  is  padded 
with  cotton  and  fitted  to  the  shoulder  and  arm.  The  splint 
and  arm  are  next  secured  to  the  side  of  the  body  by  spiral 
turns  of  a  roller-bandage,  including  the  arm  and  chest  in 
its  turns  and  applied  from  the  elbow  to  the  top  of  the 
shoulder.  The  forearm  is  carried  in  a  narrow  sling  sus- 
pended from   the  neck  (Fig.  262).     This  dressing  should 


366  FRACTURES. 

be  removed  at  the  end  of  twenty-four  or  forty-eight  hours, 
and  after  the  parts  have  been  inspected  and  sponged  with 
alcohol  the  dressings  should  be  reapplied  in  the  same 
manner,  and  if  the  patient  is  comfortable  they  need  not  be 
disturbed  again  for  three  or  four  days,  subsequent  dress- 
ings being  made  at  the  same  intervals.  Union  in  fractures 
of  the  upper  extremity  of  the  humerus,  except  in  those 
within  the  capsule,  in  which  bony  union  is  the  exception, 
is  usually  quite  firm  at  the  end  of  five  or  six  weeks,  and 
the  dressings  can  be  dispensed  with  at  this  time. 

Separation  of  the  Upper  Epiphysis  of  the  Humerus. — This 
accident  is  not  uncommon  in  patients  under  twenty  years 

Fig.  263. 


Separation  of  upper  epiphysis  of  the  humerus. 

of  age,  and  may  be  confused  with  fracture  of  the  neck  of 
the  humerus.  There  is  usually  a  marked  projection  of  the 
upper  extremity  of  the  lower  fragment  in  front  of  the 
shoulder  (Fig.  263). 

Treatment. — This  consists  in  reducing  the  displacement 
by  manipulation,  and  the  dressing  is  similar  to  that  em- 


FRACTURES  OF  THE  HUMERUS. 


367 


ployed  in  fracture  of  the  neck  of  the  humerus  (Fig.  26:2). 

Tlu'  functional  result  following  this  injury  is  usuallv  very 
good. 

Fracture  of  the  Shaft  of  the  Humerus. — This  fracture 
may  occur  at  any  point  between  the  surgical  neck  and  the 
condyles  of  the  humerus ;  the  line  of  fracture  is  usually 
oblique. 

Treatment. — This  consists  in  the  application  of  a  pri- 
mary roller  from  the  tips  of  the  fingers  to  the  seat  of  fract- 
ure ;  a  short,  well-padded,  wooden  splint  extending  from 
the  axilla  to  a  point  a  little  above  the  internal  condyle  is 
next  placed  on   the  inner  surface  of  the  arm  and  against 

Fig.  264. 


Internal  angular  splints. 

the  chest ;  a  moulded  pasteboard  or  felt  splint,  fitted  to 
the  shoulder  and  outer  side  of  the  arm  and  extending  a 
short  distance  below  the  seat  of  fracture,  is  padded  with 
cotton  and  applied  to  the  shoulder  and  arm.  The  splints 
are  held  in  position  by  the  turns  of  a  bandage,  and  the 
arm  is  secured  to  the  body  by  spiral  turns  of  a  roller-band- 
age carried  around  the  chest  and  arm,  and  the  forearm  is 
carried  in  a  sling  suspended  from  the  neck.  The  dressing 
is  much  the  same  as  that  for  fracture  of  the  upper  part  of 
the  humerus,  with  the  addition  of  the  short  internal  splint. 
Fracture  of  the  shaft  of  the  humerus  may  also  be  dressed 
by  first  applying  a  primary  roller  and  then  placing  the  fore- 
arm and  arm  upon  a  well-padded  internal  angular  splint 


368 


FRACTURES. 


(Fig.  264).  Care  should  be  taken  to  see  that  the  end  of 
the  splint  extends  only  to  the  axilla  and  does  not  press 
upon  the  brachial  vein.  A  pasteboard  or  felt  moulded 
splint  is  next  applied  to  the  shoulder  and  outer  side  of  the 
arm,  and  should  be  long  enough  to  extend  below  the 
seat  of  fracture.  The  splints  are  held  in  position  by  turns 
of  a  roller-bandage  beginning  at  the  fingers  and  carried 

up  to  the  shoulder,  and  fin- 
Fig.  265.  ished  with  a  few  spica-of- 

the-shoulder  turns  (Fig. 
266).  If  there  is  great 
overlapping  of  the  frag- 
ments producing  marked 
shortening,  the  patient 
should  be  kept  in  bed 
and  the  elbow  flexed,  and 
weight  or  elastic  extension 
made  by  adhesive  strips 
applied  to  the  arm,  short 
coaptation  splints  also  be- 
ing applied.  If  the  patient 
is  treated  as  a  walking 
case,  the  same  result  can 
be  accomplished  with  a 
bag  of  shot  or  weight  fast- 
ened to  the  arm  so  as  to 
hang  below  the  elbow  (Fig. 
265).  The  arm  is  sup- 
ported by  a  sling  applied 
at  the  wrist,  and  sometimes 
for  additional  security  the 
arm  is  bound  to  the  side  of 
the  body  by  spiral  turns  of 
a  bandage  carried  around 
the  arm  and  chest.  The  after-treatment  of  these  fractures 
as  regards  the  removal  and  renewal  of  the  dressings  is  the 
same  as  in  cases  of  fracture  of  the  upper  portion  of  the 
humerus ;  the  dressings  should  be  retained  for  five  or  six 
weeks. 


Weight  extension  in  fracture  of  the 
shaft  of  the  humerus. 


FRACTURES  OF  THE  HUMERUS.  369 

Fig.  266. 


Dressing  for  fracture  of  the  shaft  of  the  humerus  with  internal  angular  splint 
and  external  splint  of  binders'  board. 

Fractures  of  the  Lower  Extremity  of  the  Humerus. — These 
include  fractures  at  the  base  of  the  condyles,  splitting  fract- 
ures between  the  condyles  or  those  of  the  internal  or  exter- 
nal condyle,  and  epiphyseal  separation  of  the  lower  epiphysis 
of  the  humerus. 

Treatment. — The  displacement  is  reduced  by  extension 
and  manipulation,  and  before  applying  any  splint  it  is 

Ftg.  267. 


Anterior  angular  splint. 


well  in  many  cases  to  apply  over  the  region  of  the  fracture 
several  layers  of  cotton-wadding.  An  anterior  angular 
splint  (Fig.  267)  well  padded  with  cotton  or  oakum  is 
next  applied  and  held  in  position  by  the  turns  of  a  roller- 

24 


370 


FRACTURES. 


bandage  applied  from  the  fingers  to  the  upper  portion  of 
the  splint  (Fig.  268).  These  fractures  may  also  be  dressed 
with  a  well-padded  internal  angular  splint,  this  splint 
being  substituted  by  an  anterior  angular  splint  at  the  end 
of  ten  days  or  two  weeks. 

Some  surgeons  prefer  to  dress  fractures  of  the  condyles 
of  the  humerus  with  the  arm  in  the  extended  position  upon 
a  straight  anterior  splint,  or  with  short,  narrow  pasteboard 
splints  applied  around  the  joint,  as  favoring  more  accurate 

Fig.  268. 


Dressing  for  fracture  of  the  lower  extremity  of  the  humerus  with  anterior 

angular  splint. 

coaptation  of  the  fragments,  and  diminishing  the  tendency 
to  what  is  known  as  gunstock  deformity  and  loss  of  the 
carrying  angle  (Figs.  269,  270).  If  this  position  is  em- 
ployed, a  straight  wooden  splint  is  applied  to  the  anterior 
surface  of  the  arm  and  forearm,  or  moulded  splints  of 
pasteboard  may  be  used,  and  after  the  union  is  moderately 
firm,  at  the  end  of  two  weeks,  the  elbow  should  be  flexed 
and  kept  in  this  position  during  the  remaining  time  of  the 
treatment. 

Treatment  by  Acute  Flexion  (Jones's  Method). — In  this 
dressing  of  fractures  of  the  condyles  of  the  humerus,  the 
forearm  is  placed  in  a  position  of  acute  flexion  at  the 
elbow,  and  the  hand  of  the  injured  arm  is  brought  up  and 
is  supported  by  a  sling  carried  around  the  neck  (Fig. 


FRACTURES   OF  THE  HUMERUS. 

Fig.  269. 

%7^ 


371 


Gunstock  deformity  after  fracture  of  the  condyle  of  the  humerus. 

Fig.  270. 


Showing  loss  of  carrying  angle  after  fracture  of  the  condyle  of  the  humerus. 


372 


FRACTURES. 


271).  The  flexion  of  the  forearm  on  the  arm  may  also  be 
secured  by  passing  broad  strips  of  adhesive  plaster  around 
the  arm  and  forearm.  This  dressing  is  applied  for  three 
or  four  weeks,  and  then  removed  and  the  arm  gradually 
extended.  It  is  held  that  by  this  method  of  dressing 
better  motion  is  obtained,  and  the  tendency  to  gnnstock 
deformity  is  diminished. 

When  fractures  of  the  lower  extremity  of  the  humerus 
involve  the  elbow-joint,  a  certain  amount  of  impairment 

Fig.  271. 


Dressing  for  fracture  of  condyles  of  humerus  in  acute  flexion. 

of  joint-motion  is  apt  to  occur  either  from  anchylosis  or 
from  displacement  of  the  fragments,  giving  rise  to  gnnstock 
deformity  and  loss  of  the  carrying  angle,  which  in  many 
cases  it  is  impossible  to  reduce  completely,  so  that  flexion 
and  extension  of  the  joint  are  restricted.  Bearing  these 
facts  in  mind,  it  is  well  to  make  passive  motion  in  these 
cases  as  early  as  the  second  or  third  week.  It  is  well  to  ex- 
plain to  the  patient  or  his  friends  that  impairment  of  joint- 


FRACTURES  OF  THE  OLECRANON.  373 

motion  may  result  in  these  fractures  in  spite  of  the  great- 
est skill  and  care  in  the  treatment.  In  a  case  of  fracture 
in  the  region  of  the  condyles  of  the  humerus  the  dressings 
should  be  removed  in  twenty-four  hours,  and  should  be 
redressed  in  the  same  manner,  and  if  the  swelling  does 
not  increase  and  the  dressing  is  comfortable  to  the  patient 
it  should  afterward  be  dressed  at  less  frequent  intervals ; 
the  union  is  generally  quite  firm  at  the  end  of  four  weeks, 
and  the  splint  may  be  removed  at  this  time.  Fractures 
of  the  condyles  of  the  humerus  are  very  common  in 
children,  and  epiphyseal  separations  of  the  lower  epiphysis 
of  the  humerus  are  also  met  with  ;  the  dressing  of  these 
injuries  in  this  class  of  patients  is  similar  to  that  described 
for  fractures  of  the  condyles  of  the  humerus. 

Fractures  of  the  Olecranon  Process  of  the  Ulna. — 
Fracture  of  the  olecranon  may  consist  in  simply  a  sepa- 
ration of  the  cortical  layer  of  bone  over  the  summit  of 
the  process  to  which  the  triceps  is  principally  attached,  or 
the  line  of  fracture  may  pass  through  the  sigmoid  fossa. 

Treatment. — This  fracture  is  dressed  with  the  arm 
slightly  flexed  at  the  elbow,  or  with  it  completely 
extended ;  the  former  position  is  possibly  a  little  less  irk- 
some to  the  patient.  The  separation  of  the  fragment  by 
the  action  of  the  triceps  muscle  is  usually  not  very 
marked  ■  but,  if  the  displacement  is  considerable,  it  may 
in  a  measure  be  overcome  by  the  use  of  a  compress  above 
the  fragment,  over  which  figure-of-eight  strips  of  adhesive 
plaster  are  fastened  to  draw  it  down  into  position  (Fig. 
272).  The  ends  of  the  strip  are  then  attached  to  a  well- 
padded  straight  splint  which  should  be  long  enough  to 
extend  from  the  upper  third  of  the  arm  to  the  ends  of 
the  fingers,  and  is  secured  in  position  by  the  turns  of  a 
roller  carried  from  the  fingers  to  the  upper  extremity  c-f 
the  splint,  with  figure-of-eight  turns  at  the  elbow  to  rein- 
force the  action  of  the  strips  of  plaster  (Fig.  273). 

This  fracture  may  also  be  dressed  by  first  applying  a 
primary  roller  to  the  elbow,  and  then  placing  over  the 
arm  a  Veil-padded  anterior  obtuse-angled  splint,  or  a 
straight  splint  with  a  good-sized  pad  of  lint  or  oakum 


374 


FRACTURES. 


fastened  at  a  point  corresponding  to  the  position  of  the 
flexure  of  the  elbow.  When  either  of  these  splints  is 
placed  upon  the  arm  a  position  of  moderate  flexion  is  ob- 
tained. A  compress  of  lint  is  next  placed  above  the  frag- 
ment, if  there  is  a  displacement,  and  one  or  two  narrow 


Fig.  272. 


Adhesive  straps  applied  in  fracture  of  the  olecranon. 

strips  of  adhesive  plaster  are  fastened  over  this  and  passed 
obliquely  downward  and  attached  to  the  splint  on  either 
side.  The  splint  is  then  securely  fastened  to  the  arm  by 
the  turns  of  a  roller-bandage  applied  from  the  fingers  to 
the  upper  end  of  the  splint. 

Fig.  273. 


Fracture  of  olecranon  dressed  in  the  extended  position. 

The  dressings  should  be  removed  at  the  end  of  twenty- 
four  or  thirty-six  hours,  or  sooner  if  there  is  evidence  of 
swelling  of  the  tissues  in  the  region  of  the  fracture,  and 
they  should  be  reapplied  in  the  same  manner.  If  the 
dressing  is  comfortable  to  the  patient,  and  there  is  no  evi- 


FRACTURES  OF  THE   ULNA   AND  RADIUS.       375 

dence  of  swelling,  the  subsequent  dressings  should  be 
made  at  less  frequent  intervals  ;  the  dressings  are  usually 
retained  in  this  fracture  for  five  or  six  weeks.  Passive 
motion  should  not  be  made  until  this  time,  as  flexion  of 
the  elbow  tends  to  separate  the  fragments,  unless  union 
has  taken  place.  The  union  of  a  fracture  of  the  olecranon 
is  in  most  cases  fibrous,  but  in  a  few  instances  bony  union 
has  been  observed. 

Fracture  of  the  Coronoid  Process  of  the  Ulna. — 
Fracture  of  the  coronoid  process  is  an  extremely  rare 
injury. 

Treatment. — This  is  accomplished  by  placing  the  arm 
in  a  flexed  position  and  applying  a  well-padded  internal 
right-angled  splint,  or  an  anterior  right-angled  splint,  and 
securing  it  to  the  arm  by  the  turns  of  a  roller-bandage. 
A  moulded  pasteboard  or  leather  gutter  may  be  substituted 
for  the  angular  splint.  The  dressings  should  be  changed 
at  intervals,  and  after  their  removal,  at  the  end  of  three 
or  four  weeks,  passive  motion  should  be  practised. 

Fractures  of  the  Head  and  Neck  of  the  Radius. — 
These  fractures  are  also  quite  rare. 

Treatment. — This  consists  in  reducing  the  fragments  by 
manipulation,  by  flexing  the  elbow  and  keeping  it  in  this 
position,  and  by  the  application  of  a  well-padded  anterior 
right-angled  splint,  the  splint  being  firmly  secured  in  posi- 
tion by  the  turns  of  a  roller-bandage  applied  from  the  tips 
of  the  fingers  to  the  upper  end  of  the  splint  (Fig.  268). 
The  splint  should  be  changed  at  intervals,  and  should  not 
be  permanently  removed  for  four  weeks,  at  which  time 
passive  motion,  consisting  in  flexion  and  extension  at  the 
elbow  and  pronation  and  supination  of  the  forearm,  should 
be  made. 

An  internal  angular  splint  applied  to  the  inner  surface 
of  the  forearm  and  arm  may  also  be  used  in  the  treatment 
of  these  fractures  (Fig.  264). 

Fractures  of  the  Ulna  and  Radius. — These  fractures 
are  often  met  with  as  the  result  of  direct  or  indirect 
violence. 

Treatment.— After  reducing  the  displacement,  which  is 


376  FRACTURES. 

always  marked  when  both  bones  are  broken,  by  making 
extension  from  the  hand  and  by  manipulation,  the  forearm 
is  placed  in  the  supine  position  or  in  a  position  between 
pronation  and  supination.  The  supine  position  is,  as  a 
rule,  to  be  preferred  in  any  fracture  of  the  radius,  as  the 
upper  fragment  is  supinated  by  the  action  of  the  biceps 
and  supinator  brevis  muscles,  and,  therefore,  unless  the 
lower  fragment  be  placed  in  the  supine  position,  union 
with  rotary  deformity  will  almost  inevitably  ensue. 

Two  straight  wooden  splints,  well  padded,  a  little  wider 
than  the  forearm,  are  employed.  The  anterior  splint 
should  be  long  enough  to  extend  from  the  elbow  to  the 
tips  of  the  fingers,  and  the  posterior  splint  should  extend 

Fig.  274. 


Dressing  for  fracture  of  both  bones  of  the  forearm. 

from  the  elbow  to  the  wrist.  A  primary  roller  should 
never  be  applied  to  the  forearm  in  dressing  these  fractures, 
as  its  application  diminishes  the  interosseous  space,  and  its 
use  has  been  followed  by  gangrene  of  the  hand  and  fore- 
arm. In  applying  the  anterior  splint  to  the  palmar  sur- 
face of  the  forearm  and  hand,  care  should  be  taken  that 
the  upper  end  of  the  splint  does  not  press  upon  the 
brachial  artery  and  basilic  vein  at  the  elbow  when  the 
forearm  is  flexed  ;  the  posterior  splint  is  next  applied  from 
the  elbow  to  the  wrist,  and  the  splints  are  held  in  position 
by  the  turns  of  a  bandage  carried  from  the  fingers  to  the 
elbow  (Fig.  274). 

In  dressing  this  fracture  a   posterior  splint  equal    in 


FRACTURE  OF  LOWER  END   OF  THE  RADIUS.     377 

length  to  the  anterior  splint  may  be  used  in  plaee  of  the 
short  posterior  splint  extending  from  the  elbow  to  the 
wrist. 

In  fracture  either  of  the  shaft  of  the  radius  or  of  the 
ulna  alone,  the  deformity  is  usually  not  so  marked  as 
when  both  bones  are  broken  at  the  same  time,  the  un- 
broken bone  acting  as  a  splint ;  the  dressing  for  these 
fractures  is  the  same  as  for  fracture  of  both  bones  of  the 
forearm. 

The  dressing  should  be  removed  in  twenty-four  or 
thirty-six  hours,  and  after  inspecting  the  parts  and  spong- 
ing them  with  dilute  alcohol,  the  splints  should  be  replaced 
in  the  same  manner  and  secured.  The  dressings  should 
be  renewed  at  intervals  of  two  or  three  days  for  two  weeks 
at  least,  and  after  this  time  the  dressings  should  be  made 
at  less  frequent  intervals.  The  time  required  for  union  in 
these  fractures  is  usually  five  or  six  weeks,  and  the  splints 
should  be  retained  for  this  time. 

Incomplete  Fractures  of  the  Ulna  and  Radius. — 
In  children  these  fractures  are  very  common. 

Treatment. — The  deformity  is  reduced  by  bending  the 
bones  back  into  place,  often  converting  the  incomplete 
fracture  into  a  complete  one.  After  reduction  of  the  de- 
formity, the  treatment  adopted  is  the  same  as  that  de- 
scribed above.  In  these  patients  there  is  a  great  tendency 
to  displace  the  splints  or  rather  to  draw,  the  forearm  out 
of  the  splints,  and  to  prevent  this  I  often  employ  an 
anterior  angular  splint,  in  place  of  the  straight  anterior 
one,  the  upper  portion  of  which,  being  fastened  to  the 
arm,  prevents  the  child  from  dragging  the  arm  out  of  the 
dressings. 

Fracture  of  the  Lower  End  of  the  Radius. — The 
most  common  fracture  of  the  radius  is  one  situated  from 
one-half  of  an  inch  to  one  and  one-half  inches  above  the 
lower  articular  surface  of  the  bone  (Colles\s  fracture),  the 
line  of  fracture  being  more  or  less  transverse,  although  it 
may  in  some  cases  be  slightly  oblique  ;  the  characteristic 
deformity  in  this  fracture  is  represented  in  Fig.  275. 
Numerous  #-ray  studies  of  this  fracture  have  shown  that  it 


378 


FRACTURES. 


is  a  much  more  complicated  injury  than  was  formerly  sup- 
posed, being  often  comminuted  or  impacted  and  associated 
with  a  fracture  of  the  styloid  process  of  the  ulna  or  of  the 
scaphoid  or  semilunar  bones. 


Fig.  275. 


Fracture  of  the  radius  near  its  lower  extremity, 


Treatment. — The  most  important  point  in  the  treatment 
of  this  fracture  is  to  effect  complete  reduction  of  the  frag- 
ments before  the  application  of  any  splint ;  this  is  done 
,by  making  extension  from  the  hand,  and,  at  the  same 
time,  by  over-extending  and  then  flexing  the  wrist  and 
by  manipulation,  the  deformity  can  usually  be  completely 

Fig.  276. 


Position  of  compress  in  Colles's  fracture. 

reduced.  The  arm  should  then  be  brought  into  the  posi- 
tion of  supination,  and  a  firm  compress  of  lint  is  next 
placed  over  the  lower  end  of  the  upper  fragment  on  the 
palmar  surface  of  the  forearm  ;  a  second  compress  is  then 
placed  over  the  upper  end  of  the  lower  fragment  (Fig. 
276),  and  a  well-padded  Bond's  splint  (Fig.  277)  is  applied 


FRACTURE  OF  LOWER   END   OF  THE  -RADIUS.      379 

to  the  palmar  .surface  of  the  arm  and  held  in  place  by  the 
turns  of  a  roller-bandage  (Fig.  278). 


Bond's  splint. 


Many  surgeons  treat  this  fracture  with  the  hand  in  a 
position   between    pronation  and    supination^  the   thumb 


Fig.  278. 


Dressing  for  fracture  of  the  lower  end  of  the  radius. 

pointing  upward.     A  substitute  for  Bond's  splint  may  be 
prepared  by  fastening  a  roller-bandage  obliquely  upon  a 

Fig.  279. 


Substitute  for  Bond's  splint. 


straight  wooden  splint  as  suggested  by  Dr.  Hays  (Fig. 
279). 


380  FRACTURES. 

Another  method  of  treating  Colles's  fracture  after  the 
reduction  of  deformity  consists  in  placing  upon  the  dorsal 
surface  of  the  forearm  a  padded  straight  splint,  extending 
from  the  elbow  to  the  tips  of  the  fingers,  and  a  short 
straight  splint  upon  the  palmar  surface  of  the  arm,  ex- 
tending from  the  elbow  to  the  wrist  (Fig.  280).  These 
splints  are  held  in  position  by  a  bandage,  and  the  forearm 
carried  in  a  sling  with  the  hand  inclined  to  the  ulnar  side 

Fig.  280. 


Anterior  and  posterior  splints  applied. 

(Fig.  281).  The  hand  should  be  bandaged  to  the  posterior 
splint  for  about  seven  days  and  then  set  free.  The  pos- 
terior splint  should  be  left  long  for  another  week ;  at  the 
end  of  this  time  it  should  be  shortened  so  as  to  extend 
only  to  the  wrist-joint,  and  the  patient  should  be  en- 
couraged to  use  the  fingers  and  make  motions  of  the  wrist. 
At  the  end  of  three  weeks  both  splints  should  be  removed, 
and  the  patient  should  carry  the  forearm  in  a  sling  for  a 
few  weeks  longer  and  be  encouraged  to  use  the  hand. 

The  most  important  point  in  the  treatment  of  this  fract- 
ure is  the  complete  reduction  of  the  deformity  at  the  first 
dressing,  and  if  this  has  been  satisfactorily  done  almost 
any  splint  may  be  used  with  a  good  result,  and,  indeed, 
some  surgeons  use  no  splint,  applying  only  a  compress 
over  the  seat  of  fracture,  held  in  place  by  a  strip  of 
plaster,  the  arm  being  carried  in  a  sling. 

The  after-treatment  of  these  fractures  consists  in  remov- 
ing the  splint  and  compresses  after  twenty-four  or  thirty- 


REVERSED   COLLES'S  FRACTURE.  381 

six  hours  and  in  sponging  the  surface  of  the  skin  with 
dilute  alcohol,  and  the  compresses  and  splints  should  then 
be  reapplied  in  the  same  manner ;  the  fracture  should  be 
dressed  every  second  or  third  day  for  the  first  two  weeks, 
and  after  this  time  it  should  be  dressed  at  less  frequent 
intervals.  Union  is  usually  quite  firm  at  the  end  of  four 
weeks,  and  the  splint  should  be  dispensed  with  at  this 
time.     A   certain   amount  of   stiffness  of  the  wrist  and 

Fig.  281. 


Dressing  for  Colles's  fracture  with  long  posterior  and  short  anterior  splint. 

fingers  is  apt  to  follow  this  fracture,  which  is  usually  soon 
overcome  by  passive  motion  and  physiological  use  of  the 
parts. 

Epiphyseal  Separation. — In  children  separation  of  the 
lower  epiphysis  of  the  radius  is  often  met  with,  and  its 
treatment  is  similar  to  that  described  above ;  a  Bond  splint 
with  compresses  or  two  straight  splints  with  compresses 
being  the  most  satisfactory  dressing  to  employ  in  this  in- 
jury, the  dressings  being  retained  for  three  weeks. 

Reversed  Colles's  Fracture. — This  is  a  rare  fracture 
of  the  lower  end  of  the  radius  in  which  the  lower  frag- 
ment is  displaced  forward  instead  of  backward,  the  de- 
formity being  the  reverse  of  that  seen  in  Colles's  fracture. 

Treatment. — This  consists  in  the  reduction  of  the  de- 
formity, the  manipulation  being  the  reverse  of  that  em- 
ployed in  Colles's  fracture,  and  the  dressings  are  similar 
to  those  employed  in  the  latter,  with  the  exception  that 
the  position  of  the  compresses  is  reversed. 


382  FRACTURES. 

Fractures  of  the  Carpal  Bones. — These  fractures  are 
usually  compound  or  open  fractures,  and  are  so  frequently 
associated  with  extensive  laceration  of  the  arm  and  hand 
that  operative  measures  have  to  be  resorted  to  ;  but  if  such 
is  not  the  case,  they  are  dressed,  when  compound,  with  an 
antiseptic  dressing,  and  the  hand  and  forearm  are  sup- 
ported upon  a  well-padded  palmar  splint  held  in  place  by 
a  roller-bandage ;  more  or  less  impairment  in  the  motion 
of  the  wrist  is  apt  to  follow  these  fractures.  The  dress- 
ings should  be  retained  for  three  or  four  weeks,  and  after 
their  removal  passive  motion  should  be  employed  to  over- 
come as  far  as  possible  the  joint-stiffness  resulting. 

Fractures  of  the  Metacarpal  Bones. — These  fract- 
ures are  often  met  with  as  the  result  of  direct  or  indirect 
force  applied  to  the  metacarpal  bones. 

Treatment. — This  consists  in  first  reducing  the  de- 
formity, which  is  usually  an  angular  one,  the  projection 

Fig.  282. 


V 

Agnew's  splint  for  fracture  of  the  metacarpal  bones. 

of  the  angle  being  toward  the  back  of  the  hand ;  this  is 
reduced  by  pressure  with  the  fingers,  and  the  hand  and 
forearm  should  then  be  placed  upon  a  palmar  splint  (Fig. 
282)  with  a  pad  of  oakum  or  cotton  under  the  palm  ;  a 
compress  of  lint  is  next  placed  over  the  seat  of  fracture, 
and  the  hand  and  forearm  are  bound  to  the  splint  by  the 
turns  of  a  roller-bandage  (Fig.  283).  At  the  end  of  three 
weeks  union  at  the  seat  of  fracture  is  usually  quite  firm, 
and  the  splint  should  be  dispensed  with  at  this  time. 

Fractures  of  the  Phalanges. — These  may  result  from 
direct  or  indirect  violence,  and  often  present  marked 
deformity. 

Treatment. — This  consists  in  reducing  the  displacement 
by  extension  and  manipulation,  and  in  placing  the  finger 


FRACTURES  OF  THE  PHALANGES. 


383 


in  a  moulded  gutta-percha  or  pasteboard  splint  (Fig.  2<S4), 
and  securing  the  splint  in  position  by  the  turns  of  a  roller- 
bandage.  When  the  proximal  phalanx  is  fractured,  a  nar- 
row padded  wooden   splint  extending  from  the  end  of  the 


Fio.  283. 


» 


Dressing  for  fracture  of  the  metacarpal  bones. 


finger  to  the  wrist  should  be  applied  upon  the  palmar  sur- 
face of  the  finger  and  hand,  and  a  short  dorsal  splint  should 
also  be  used  ;  if  there  is  a  tendency  to  lateral  displacement, 
short  lateral  splints  should  also  be  employed,  and  the 
splints  should  be  held  in  place  by  strips  of  plaster  or  by 

Fig.  284. 


Gutta-percha  splint  for  fracture  of  phalanx.     (Hamilton.) 

a  roller-bandage  (Fig.  285).  Splints  made  from  a  piece 
of  wire  may  be  fitted  to  the  finger  and  secured  in  the 
same  manner.- 

Union  in  fractures  of  the  phalanges  is  usually  firm  at 
the  end  of  three  weeks,  and  the  splints  can  be  dispensed 
with  at  that  time. 


384  FRACTURES. 

Fig.  285. 


Dressing  for  fracture  of  phalanx  with  anterior  and  posterior  splints. 

Fractures  of  the  Femur. — These  may  involve  the  neck, 
great  trochanter,  and  upper  end  of  the  shaft,  the  shaft,  or 
the  lower  extremity  of  the  bone. 

Fractures  of  the  Upper  Extremity  of  the  Femur. — These 
may  involve  the  head,  neck,  the  great  trochanter,  and  the 
upper  portion  of  the  shaft  of  the  femur. 

Treatment. — The  patient  should  be  placed  in  bed  upon 
a  firm  mattress,  and  an  extension  apparatus  made  from 
adhesive  plaster  should  be  applied  to  the  leg,  extending 
as  far  as  the  knee-joint.  The  extension  apparatus  is 
constructed  by  taking  a  piece  of  adhesive  plaster  two 
and  a  half  inches  in  width  and  long  enough  to  extend 
from  the  outer  side  of  the  knee  or  middle  of  the  thigh 
to  four  inches  below  the  sole  of  the  foot,  and  from  this 
point  back  to  the  inner  side  of  the  knee  or  middle  of 
the  thigh  ;  in  the  centre  of  this  strip  is  placed  a  block 
of  wood,  two  and  a  half  inches  wide  and  four  inches  in 
length,  with  a  perforation  in  its  centre ;  the  block  and 
the  inner  surface  of  the  strip  on  each  side  are  next  faced 
with  a  similar  strip  of  adhesive  plaster  to  a  point  about 
an  inch  above  each  malleolus ;  a  few  straps  are  next 
wound  around  the  wooden  block  to  fix  the  previously 
applied  straps ;  the  strip  of  plaster  is  next  warmed  and 
applied  to  the  sides  of  the  leg  and  held  in  position  by 
three  or  four  strips  of  adhesive  plaster  carried  around  the 
leg  at  intervals  (Fig.  286),  and  the  plaster  is  made  addi- 
tionally   secure    by  the  application    of  a    roller-bandage 


FRACTURES   OF   THE  FEMUR. 


385 


applied  to  tlif  foot  and  leg  and  carried  up  to  the  knee. 
Yolkmann's  sliding  foot-piece  may  be  employed  to  make 
the  extension  more  effective  (Fig.  287). 


Fig.  2S6. 


Adhesive  plaster  extension  apparatus  applied  to  limb.    (Ashhxrst.) 

Through  the  perforation  in  the  block  or  stirrup  is  fast- 
ened a  cord  which  passes  over  a  pulley  attached  to  the 
bed,  and  to  this  cord  is  attached  the  extending  weight. 

Fig.  287. 


Volkmann's  sliding  foot-piece. 


The  extension  apparatus  being  applied,  lateral  support  is 
given  to  the  leg  and  thigh  by  sand  bags  applied  on  either 
side ;  the  outer  sand  bag  should  extend  from  the  foot  to 


2b 


386  FRACTURES. 

the  axilla,  and  the  inner  one  from  the  foot  to  the  groin. 
A  weight  of  five  or  ten  pounds  is  attached  to  the  extend- 
ing cord,  and  the  lower  feet  of  the  bed  should  be  raised  on 
blocks  a  few  inches  high,  to  prevent  the  patient  from  slip- 
ping down  in  bed  ;  a  pad  of  oakum  or  cotton  should  also 
be  placed  under  the  tendo-Achillis,  to  relieve  the  heel  from 
pressure.  This  dressing  is  kept  in  place  for  from  four  to 
six  weeks,  and  if  union  has  occurred  the  patient  is  kept 
in  bed  for  a  few  weeks  longer  and  is  then  allowed  to  be 
about,  using  crutches.  In  the  majority  of  cases  of  fract- 
ure of  the  neck  of  the  femur  fibrous  union  only  takes 
place,  and  after  employing  the  dressing  before  described 

Fig.  288. 


Smith's  anterior  splint  for  fracture  of  the  femur. 

for  six  weeks  the  patient  is  allowed  to  get  up  and  go  about 
on  crutches.  It  often  happens  that  the  subjects  in  whom 
these  fractures  occur  are  old  and  feeble,  and  if  it  is  found 
that  restraint  in  bed  with  the  dressings  here  described  is 
not  well  borne,  under  such  circumstances  they  should  be 
discarded  and  the  patient  allowed  to  sit  up  in  bed  with 
the  limb  resting  on  a  pillow,  or  to  get  into  a  chair,  the 
treatment  of  the  local  condition  having  to  be  disregarded, 
attention  being  given  to  the  patient's  constitutional  con- 
dition. 

In  fractures  of  the  neck  of  the  femur  and  of  the  upper 


FRACTURES  OF  THE  FEMUR. 


387 


part  of  the  shaft  of  the  bone  the  anterior  wire  splint  of 
Professor  X.  R.  Smith  is  sometimes  used  with  advantage; 
the  limb  being  swung  from  the  splint,  the  patient  is  able 
to  move  in  bed  without  causing  him  pain  or  disturbing 
the  fragments  (Fig.  288).  In  fractures  in  the  upper  por- 
tion of  the  femur  where  there  is   marked  tilting  forward 

Fig.  289. 


Dressing  for  fracture  of  the  femur  with  extension  upon  an  inclined  plane. 

(Agnew.) 

of  the  upper  fragment  Professor  Agnew  employed  exten- 
sion made  from  the  thigh  and  placed  the  limb  upon  a 
double  inclined  plane,  maintaining  this  position  during  the 
treatment  of  the  case  (Fig.  289).     With  the  same  object 


Fig.  290. 


Double  inclined  fracture-box. 


in  view,  in  place  of  the  double  inclined  plane  a  double 
inclined  fracture-box  may  be  employed  (Fig.  290),  exten- 
sion being  made  from  the  thigh  by  means  of  adhesive 


388  FRACTURES. 

plaster  strips  applied  above  the  knee,  to  which  a  weight 
is  attached. 

Fracture  of  the  Shaft  of  the  Femer. — This  is  a  fre- 
quent fracture,  and  is  usually  accompanied  by  marked 
shortening  and  angular  or  rotatory  displacement  of  the 
fragments. 

Treatment. — The  patient  should  be  placed  upon  a  fract- 
ure-bed or  an  ordinary  bed  with  a  firm  hair  mattress;  an 
extension  apparatus  of  adhesive  plaster  is  applied,  and 
extension  is  made  by  a  weight  attached  to  this,  as  pre- 
viously described.  Lateral  support  is  given  to  the  limb 
by  the  application  of  two  wooden  splints — the  outer  or 
long  one  extending  from  the  axilla  to  the  foot,  the  inner 
or  short  one  extending  from  the  groin  to  the  foot.  The 
splints  at  their  upper  extremity  should  be  about  six 
inches  in  width  and  at  their  lower  extremity  about  three 
and  a  half  inches.  The  splints  are  wrapped  in  a  splint 
cloth,  which  extends  from  the  foot  to  the  groin,  and  after 
this  has  been  placed  under  the  limb  the  splints  are  fixed 
in  their  proper  positions,  the  short  one  to  the  inner  side, 
the  long  one  to  the  outer  side  of  the  limb.  Between  the 
limb  and  the  splints  are  interposed  bran  bags  :  the  outer 
bag  should  be  long  enough  to  extend  from  the  axilla  to 
the  foot,  the  inner  one  from  the  groin  to  the  foot.  The 
splints  and  bran  bags  are  held  in  place  by  five  or  six 
strips  of  bandage  passing  under  the  limb  and  body  and 
around  the  splints  and  bran  bags  at  intervals.  The  heel 
is  saved  from  pressure  by  placing  a  wad  of  oakum  or 
cotton  under  the  tendo-Achillis,  and  after  the  splints  have 
been  brought  into  place  the  strips  of  bandage  are  firmly 
tied  to  secure  them,  and  a  weight  of  ten  or  twelve  pounds 
is  attached  to  the  extending  cord.  The  foot  of  the  bed  is 
raised,  to  prevent  the  patient  from  slipping  downward  and 
to  allow  the  weight  of  the  body  to  act  as  a  counter- 
extending  force.  After  the  application  of  the  dressings 
the  thigh  should  be  slightly  abducted.  During  the  after- 
treatment  of  these  fractures  the  surgeon  should  see  that 
the  splints  and  bran  bags  are  kept  firmly  in  place,  and  that 
the  foot  does  not  roll  outward ;  this  is  accomplished  by 


FRACTURES  OF  THE  FEMUR. 


389 


untying  the  strips  and  readjusting  the  bags,  and  then 
bringing  up  the  splints  and  securing  them  in  position  by 
fastening  the  strips  (Fig.  291).  The  extension  apparatus 
usually  does  not  require  renewal  during  the  course  of 
treatment.  The  extension  apparatus  and  splints  are  kept 
in  place  for  four  or  six  weeks,  and  at  this  time  union  at 
the  seat  of  fracture  is  usually  quite  firm,  so  that  they  may 
be  removed,  and  the  fracture  is  then  supported  by  moulded 
pasteboard  splints  or  by  the  application  of  a  plaster-of- 
Paris  splint  for  several  weeks  longer,  and  at  the  end  of 
eight  to  ten  weeks  it  is  safe  to  allow  the  patient  to  be  up 
and  around  on  crutches. 

Fig.  291. 


Dressing  for  fracture  of  the  shaft  of  the  femur  with  lateral  splints  and 
bran  bags.    (AsHHrEST.) 

Many  surgeons,  in  fracture  of  the  shaft  of  the  femur, 
prefer  to  use  a  long  external  sand  bag,  and  a  shorter 
internal  one  in  place  of  the  corresponding  long  and  short 
splints  and  bran  bags ;  if  care  is  observed  that  the  sand 
bags  are  kept  accurately  in  contact  with  the  limb  and 
body,  excellent  results  may  be  obtained  by  this  form 
of  dressing.  After  considerable  experience  with  both 
methods  of  furnishing  lateral  support  in  the  dressing  of 
fractures  of  the  shaft  of  the  femur,  I  am  well  satisfied 
that  angular  deformity  is  less  likely  to  result  where  the 
splints  and  bran  bags  are  employed. 

The  plaster-of-Paris  dressing,  including  the  foot,  leg, 


390  FRACTURES. 

thigh,  and  pelvis,  is  employed  by  some  surgeons  in  the 
early  treatment  of  fracture  of  the  shaft  of  the  femur,  the 
limb  being  kept  well  extended  until  the  plaster  has  thor- 
oughly set.  In  applying  this  dressing,  the  patient  should 
be  placed  upon  the  pelvic  supporter  (see  page  96). 

Fracture  of  the  Lower  End  of  the  Femur. — The 
fractures  met  with  in  this  portion  of  the  femur  are  supra- 
condyloid  fractures,  those  in  which  one  condyle  is  sepa- 
rated from  the  other,  or  comminuted  fractures,  in  which 
both  condyles  are  separated ;  epiphyseal  disjunctions  of 
the  lower  end  of  the  femur,  met  with  in  young  subjects, 
may  also  be  classed  with  fractures  at  this  portion  of  the 
bone. 

Treatment. — If  there  is  shortening,  the  dressing  should 
be  similar  to  that  employed  in  fractures  of  the  shaft  of 
the  femur,  consisting  in  the  application  of  an  extension 
apparatus  and  bran  bags  and  splints  or  sand  bags  to  give 
lateral  support ;  if,  however,  there  is  no  marked  shorten- 
ing, the  dressing  employed  should  be  the  same  as  that 
applied  in  fractures  involving  one  or  both  condyles  or 
epiphyseal  separation. 

The  dressing  employed  in  fracture  of  one  or  both  con- 
dyles or  in  epiphyseal  disjunction  of  the  lower  end  of 
the  femur  consists  in  placing  the  limb  in  a  fracture-box 
extending  from  the  foot  to  the  upper  third  of  the  thigh, 
the  box  being  well  padded  with  a  soft  pillow,  or  a  well- 
padded  posterior  splint,  or  a  moulded  pasteboard  or  felt 
gutter  may  be  employed ;  if  either  of  these  dressings  is 
employed,  the  splint  or  gutter  should  be  sufficiently  long 
to  extend  from  the  lower  part  of  the  leg  to  the  upper  part 
of  the  thigh. 

At  the  end  of  two  weeks  it  is  well  to  place  the  limb 
in  a  plaster-of-Paris  dressing  extending  from  the  foot 
to  the  upper  part  of  the  thigh.  This  dressing  should 
be  retained  for  six  weeks;  at  the  end  of  this  time  the 
dressing  should  be  removed,  and  if  union  is  sufficiently 
firm  to  allow  the  patient  to  go  about  on  crutches,  a  fresh 
plaster-of-Paris  splint  should  be  applied  extending  from 
the  middle  of  the  leg  to  the  middle  of  the  thigh,  or  lateral 


FRACTURES   OF  THE  FEMUR  391 

splints  of  pasteboard  may  be  substituted  for  the  plaster 

dressing. 

A  certain  amount  of  permanent  impairment  of  the 
joint-motion  is  apt  to  follow  fractures  involving  one  con- 
dyle or  both  condyles  of  the  femur. 
*  Fracture  of  the  Shaft  of  the  Femur  in  Children.— 
Treatment. — In  infants  the  treatment  by  extension  by  a 
weight  and  pulley  and  lateral  splints  is  often  unsatisfac- 
tory on  account  of  the  difficulty  in  keeping  the  patient 
quiet  upon  his  back,  and  from  the  soiling  of  the  dressings 
by  the  feces  and  the  urine.  In  children  two  years  of  age 
and  over  I  have  never  found  much  trouble  in  employing 
extension  and  lateral  support  by  splints  and  bran-bags  or 
sand-bags,  and  in  these  cases  I  make  additional  fixation 
at  the  seat  of  fracture,  and  guard  against  displacement 
of  the  fragments  by  the  child  sitting  up  in  bed  when  not 
watched,  by  carefully  moulding  external  and  internal 
pasteboard  or  felt  splints  to  the  thigh,  and  holding  them 
in  place  by  the  turns  of  a  bandage.  I  have  employed 
this  form  of  dressing  even  in  children  under  two  years 
of  age  with  the  most  satisfactory  results. 

In  cases  of  fracture  of  the  femur  in  children  from  a  few 
months  to  a  year  or  eighteen  months  of  age,  in  whom  it 
is  difficult  to  obtain  quietude,  or  who  have  to  be  moved  to 
give  them  nourishment  if  they  are  taking  the  breast,  the 
dressing  which  I  have  found  most  satisfactory  consists  in 
first  applying  a  roller-bandage  from  the  foot  to  the  groin, 
and  then  moulding  to  the  outer  half  of  the  foot,  leg, 
thigh,  and  also  to  half  of  the  pelvis,  a  pasteboard  or  felt 
splint  which  is  well  padded  with  cotton,  and  held  in  posi- 
tion by  the  turns  of  a  bandage  carried  from  the  foot  to  the 
pelvis  and  finished  with  circular  turns  about  the  pelvis. 
The  splint  should  be  so  moulded  as  to  include  a  little 
more  than  one-half  of  the  circumference  of  the  thigh  and 
leg.  If  this  splint  becomes  soiled,  it  is  easily  replaced  by 
a  fresh  one,  and  its  removal  and  renewal  are  much  easier 
than  the  plaster-of-Paris  splint  which  is  recommended  by 
some  surgeons  in  these  cases. 

In  young  children  fractures  of  the  femur  are  often  in- 


392 


FRACTURES. 


Fig 


complete  or  greenstick  fractures;  and  even  when  complete, 
the  shortening  is  usually  not  marked,  as  the  line  of  fract- 
ure is  apt  to  be  transverse,  the  periosteum  often  not  being 
completely  ruptured,  which  tends  to  hold  the  fragments 
in  position. 

In  green-stick  fractures  the  deformity  should  be  reduced 
by  manipulation,  even  if  it  is  necessary  to  convert  the 
incomplete  fracture  into  a  complete  one  to  accomplish 
this  object. 

Mr.  Bryant  recommends  that  fractures  of  the  femur  in 
young  children   be  treated  in   the    vertical   position ;  the 

injured  limb,  together  with  the  sound 
one,  is  flexed  at  a  right  angle  to  the 
pelvis  and  fixed  with  a  light  splint, 
and  attached  to  a  cradle  or  bar  above 
the  bed  (Fig.  292). 

If  the  plaster-of- Paris  dressing  is 
used,  the  limb  should  first  be  envel- 
oped from  the  foot  to  the  pelvis  with 
a  flannel  bandage,  and  extension 
should  be  made  while  the  plaster-of- 
Paris  bandage  is  being  applied,  and 
should  be  kept  up  until  the  bandage 
has  become  fixed.  The  plaster  band- 
age should  extend  from  the  toes  to 
the  pelvis,  and  it  is  well  to  fix  the 
hip-joint  by  carrying  several  turns 
of  the  bandage  about  the  pelvis.  To 
prevent  the  splint  from  absorbing 
the  discharges  and  becoming  offen- 
sive, the  upper  portion  of  it  may  be  coated  with  shellac. 
The  time  required  for  union  in  fractures  of  the  femur 
in  children  is  about  four  weeks,  and  the  dressings  may  be 
removed  at  this  time  ;  but  the  child  should  not  be  allowed 
to  use  the  limb  for  several  weeks  after  this  period. 

Ambulatory  Treatment  of  Fractures  of  the  Femur. — In 
this  method  of  treatment  in  fractures  of  the  femur  the 
injured  limb  is  strongly  extended,  and  a  flannel  roller  is 
applied  to  the  leg,  thigh,  and  pelvis.     A  plaster-of- Paris 


Fracture  of  the  femur 
treated  by  vertical  exten- 
sion.   (Bryant.) 


FRACTURES  OF  THE  PATELLA. 


393 


bandage  is  then  applied  from  the  toes  to  the  pelvis,  and 
is  made  to  include  the  pelvis  by  spica  and  circular  turns. 
It  should  be  well  padded  in  the  perineum,  and  the  inner 
portion  of  the  bandage  should  fit  well  in  the  region  of  the 
tuberosity  of  the  ischium.  The  plaster  dressing  should  be 
so  applied  that  upon  the  patient  standing  upon  the  limb 
the  weight  is  supported  by  the  plaster  cast  resting  upon  the 
tuberosity  of  the  ischium  and  the  expanded  portion  of  the 
ilium.  A  Taylor  hip-splint,  reinforced  by  plaster  bandages 
and  the  use  of  crutches,  with  a  high  shoe  on  the  sound 
foot,  may  be  used  in  the  ambulatory  treatment  of  fractures 
of  the  femur. 

Fractures  of  the  Patella. — These  fractures  result  from 
direct  violence  and  muscular  action. 

Treatment. — This  consists,  first,  in  the  application  of  a 
roller-bandage  from  the  toes  to  the  upper  part  of  the  leg ; 

Fig.  293. 


Agnew's  splint  for  fracture  of  the  patella. 

a  well-padded  posterior  wooden  splint  long  enough  to 
extend  from  the  middle  of  the  leo;  to  the  middle  of  the 
thigh,  or  an  Agnew  splint,  which  is  provided  with  pegs 
for  the  attachment  of  strips  of  adhesive  plaster  (Fig.  293), 
is  next  placed  under  the  limb.  A  small  compress  of 
lint  is  next  placed  above  the  upper  fragment,  and  a 
similar  compress  is  placed  below  the  lower  fragment ;  a 
strip  of  adhesive  plaster  one  and  a  half  inches  in  width 
and  twenty-four  inches  in  length  has  its  middle  portion 
applied  over  the  compress,  and  its  ends  are  then  brought 
obliquely  downward  and  fastened  to  the  splint,  or  to  the 
pegs  if  Agnew's  splint  be  used ;  this  may  be  reinforced 


394 


FRACTURES. 


by  a  second  or  third  strip.  The  object  of  these  strips 
is  to  bring  the  upper  fragment  down  in  contact  with  the 
lower  fragment.  A  strip  of  plaster  with  the  ends  passing 
in  the  opposite  direction  is  next  placed  over  the  lower 
compress,  and  the  ends  are  fastened  to  the  splint  or  pegs  ; 
this  strip  serves  only  to  steady  the  lower  fragment,  as  it 
cannot  be  drawn  upward  to  meet  the  upper  fragment  by 
reason  of  the  inextensibility  of  its  ligamentous  attachment 
(Fig.  294).  If  the  Agnew  splint  is  employed,  the  strips 
of  plaster  may  be  tightened  by  turning  the  pegs  to  which 
they  are  fastened  without  removing  the  splint. 

Fig.  294. 


Agnew's  splint  applied. 

The  splint  is  next  firmly  fixed  in  contact  with  the  limb 
by  the  turns  of  a  roller-bandage  extending  from  the  lower 
to  the  upper  end  of  the  splint.  The  limb  should  next  be 
placed  upon  an  inclined  plane  or  in  a  long  fracture-box, 
with  its  foot  elevated  to  relax  the  quadriceps  femoris 
muscle.  This  dressing  should  be  removed  and  reapplied 
in  a  few  days,  as  the  dressings  become  loose  as  the  swell- 
ing about  the  seat  of  injury  subsides,  and  after  this  disap- 
pears the  dressings  require  renewal  at  less  frequent  inter- 
vals ;  and  usually  at  the  end  of  three  weeks  the  splint  may 
be  removed  and  a  plaster-of-Paris  bandage  may  be  applied, 
extending  from  the  middle  of  the  leg  to  the  middle  of  the 
thigh.  At  the  end  of  six  weeks  the  patient  may  be  allowed 
to  walk  upon  the  limb,  the  knee-joint  being  fixed  with  a 
plaster-of-Paris  or  pasteboard  splint. 


FRACTURES  OF  THE  PATELLA.  395 

It  is  well,  after  removal  of  the  splints,  for  the  patients 
to  wear  for  some  months  a  laced  muslin  knee-supporter, 
which  gives  some  support  to  the  knee-joint. 

A  great  variety  of  splints  have  been  devised  and  used 
in  the  treatment  of  fractures  of  the  patella,  the  main  object 
of  which  is  to  fix  the  knee-joint  and  bring  the  fragments 
as  nearly  as  possible  in  apposition. 

The  union  in  fractures  of  the  patella  is  usually  fibrous, 
although  in  rare  cases  bony  union  has  occurred. 

Operative  Treatment. — This  method  of  treatment  in 
fractures  of  the  patella,  which  consists  in  exposing  the 
fragments  by  an  incision  and  drilling  and  suturing  them 
with  catgut  or  silver-wire  sutures,  or  in  suturing  the 
fibrous  tissues  with  catgut  or  in  applying  a  Barker's  cir- 
cumpatellar  suture,  is  also  employed  at  the  present  time, 
the  strictest  antiseptic  precautions  being  taken  to  prevent 
infection  of  the  wound. 

In  cases  of  rupture  of  the  fibrous  union  after  fracture 
of  the  patella,  which  is  not  an  uncommon  accident,  the 
treatment  of  the  case  should  be  the  same  as  that  for  a 
recent  fracture  of  the  patella. 

Fractures  of  the  Bones  of  the  Leg. — In  fractures 
of  both  bones  of  the  leg  the  displacement  is  usually  very 
marked.  AVhen  only  one  bone  is  broken,  the  sound  bone, 
acting  as  a  splint,  prevents  much  deformity,  except  in  cases 
of  fracture  at  the  lower  end  of  the  fibula,  when  the  foot 
inclines  to  the  injured  side. 

Treatment. — The  dressing  of  fractures  of  both  bones  of 
the  leg,  or  of  fracture  of  the  tibia  or  the  fibula  alone, 
except  in  cases  where  the  lower  portion  of  the  fibula  is  the 
seat  of  injury,  is  best  accomplished  by  the  use  of  a  fracture- 
box.  The  displacement  being  overcome  as  far  as  possible 
by  extension  and  manipulation,  the  leg  is  placed  in  a 
fracture-box,  which  is  prepared  for  the  reception  of  the 
limb  by  having  the  sides  let  down  and  having  a  soft  pillow 
laid  in  It ;  the"  foot  is  next  secured  to  the  footboard  by  a 
loop  of  bandage  passed  around  the  foot,  the  ends  being 
tied  after  passing  through  the  slots  in  the  footboard  ;  a  pad 
of  oakum  or  cotton  is  placed  under  the  tendo-Achillis,  to 


396 


FRACTURES. 


relieve  the  heel  from  pressure,  and  a  similar  pad  is  plaeed 
between  the  sole  of  the  foot  and  the  footboard  (Fig.  295). 
The  sides  of  the  box  are  then  brought  up  and  secured  by 


Fig.  295. 


Application  of  the  fracture-box. 


two  or  three  strips  of  bandage  tied  around  the  box.  In 
using  a  fracture-box  in  the  treatment  of  fractures  of  the 
bones  of  the  leg  the  surgeon  should  see  that  the  foot  is 


Fig.  296. 


Plaster  bandage  applied  to  fracture  of  the  leg. 


kept  well  down  to  the  footboard  and  is  at  a  right  angle 
with  the  leg,  that  there  is  no  eversion  of  the  knee,  and  that 
the  pillow  is  full  enough  to  make  equable  pressure  upon 
the  lee;  when  the  sides  of  the  box  are  secured,  and  that 


FRACTURES  OF   THE   BONES   OF  THE  LEG.      397 

the  heel  is  not  subjected  to  undue  pressure,  the  use  of  a 
pad  of  oakum  or  cotton  under  the  tendo- A  chillis  being 
employed  to  prevent  this  complication.  Where  there  is  a 
tendency  to  tilting  upward  of  the  lower  end  of  the  upper 
fragment,  the  lower  fragment  can  be  brought  in  line  with 

Fig.  297. 


Fracture-box  suspended.    (Agxew.) 

this  by  raising  the  foot  by  a  mass  of  oakum  or  cotton 
placed  under  the  tendo-Achillis  and  heel,  and  so  over- 
coming the  deformity.  In  some  cases  division  of  the 
tendo-Achillis  may  be  required  before  this  deformity  can 
be  corrected. 

The   subsequent  dressings   of   the   case   are  conducted 


398 


FRACTURES. 


by  letting  down  the  sides  of  the  box  and  correcting  any 
displacement,  if  present,  by  adjusting  the  limb  and  pads 
in  their  proper  position,  and  again  bringing  up  the  sides 
of  the  box  and  securing  them.  At  the  end  of  two  weeks 
the  fracture-box  may  be  removed  and  a  plaster-of-Paris 
dressing  applied  to  the  limb,  which  will  allow  the  patient 
more  freedom  of  movement  in  bed,  or  permit  of  his  sit- 
ting up  without  disturbing  the  fragments  (Fig.  296). 

Fig.  298. 


Moulded  binders'  board  splints  for  fracture  of  the  leg. 

Union  in  fracture  of  the  bones  of  the  leg  is  usually 
quite  firm  in  six  weeks,  but  for  at  least  eight  weeks  the 
patient  should  not  be  allowed  to  put  his  weight  upon  the 
limb  in  walking. 

If  the  patient  is  restless,  and  finds  his  position  with  the 
fracture-box  resting  upon  the  bed  irksome,  the  fracture- 


FRACTURES  OF  THE  BONES  OF  THE  LEG.      399 

box  may  be  swung  from  a  frame  fastened  over  the  bed 
(Fig.  297). 

The  application  of  a  plaster-of-Paris  dressing  as  a 
primary  dressing — the  ordinary  plaster-of-Paris  bandage 
or  the  Bavarian  dressing  being  applied — in  fractures  of 
the  bones  of  the  leg  is  adopted  by  some  surgeons,  and,  if 
employed,  the  case  should  be  under  constant  observation 
for  a  few  days,  so  that  the  dressing  can  be  removed  if  a 
dangerous  amount  of  swelling  takes  place.  Moulded 
splints  of  felt  or  pasteboard  are  also  sometimes  applied  in 
the  treatment  of  these  cases  (Fig.  298). 

This  fracture  may  also  be  treated  with  Volkmann's 
splint  (Fig.  299),  for  one  or  two  weeks,  until  the  swell- 
ing has  subsided,  and  then  by  a  plaster-of-Paris  dressing. 

Fig.  299. 


Volkmann's  splint. 

In  patients  suffering  with  delirium  tremens,  or  in  mani- 
acal patients,  the  use  of  a  fracture-box  in  the  treatment 
of  fractures  of  the  bones  of  the  leg  is  often  not  satisfac- 
tory, on  account  of  the  difficulty  in  restraining  the  move- 
ments of  the  patient  and  the  consequent  displacement  of 
the  fragments.  In  such  cases  it  is  well  to  apply  a  few 
strips  of  binders'  board,  well  padded  with  cotton,  to  the 
limb,  extending  above  and  below  the  seat  of  the  fracture, 


400  FRACTURES. 

holding  them  in  place  by  a  few  turns  of  a  roller,  and  then 
to  wrap  the  limb  and  foot  in  a  soft  pillow,  and  hold  this 
in  place  by  the  turns  of  a  roller-bandage  applied  with 
moderate  firmness.  This  dressing  allows  the  patient  to 
move  the  limb  without  serious  disturbance  of  the  frag- 
ments, and,  after  the  patient  recovers  from  his  attack,  the 
leg  may  be  placed  in  the  fracture-box  or  in  a  plaster-of- 
Paris  dressing. 

In  fractures  of  the  bones  of  the  leg  in  young  children 
the  same  difficulty  is  often  experienced  in  keeping  them 
quiet,  and  for  this  reason  a  fracture-box  cannot  be  used 
with  satisfaction.  In  dressing  these  cases,  two  lateral 
splints  of  pasteboard,  moulded  to  the  foot  and  leg  and 
well  padded  with  cotton,  may  often  be  employed  with  the 
best  results.  The  splints  should  not  be  wide  enough  to 
meet  on  the  anterior  or  posterior  surface  of  the  leg  or 
foot.  The  splints,  after  being  carefully  adjusted,  are  held 
in  place  by  the  turns  of  a  roller-bandage ;  and  after  these 
splints  have  been  applied  for  two  weeks,  and  all  swelling 
has  subsided  at  the  seat  of  fracture,  a  plaster-of-Paris 
bandage  may  be  substituted  for  them,  which  should  be 
worn  for  three  weeks;  at  the  expiration  of  this  time 
union  is  usually  sufficiently  firm  to  dispense  with  all  dress- 
ings. 

Ambulatory  Treatment  of  Fractures  of  the  Bones  of 
the  Leg. — The  application  of  a  dressing  for  the  ambu- 
latory treatment  of  fractures  of  the  bones  of  the  leg  is  as 
follows :  The  fracture  should  be  reduced  and  the  skin  of 
the  leg  washed  with  soap  and  water ;  a  flannel  bandage 
is  applied  from  the  toes  to  a  point  just  above  the  knee. 
This  bandage  holds  to  the  sole  of  the  foot  a  number  of 
layers  of  cotton-wadding,  which,  when  moderately  com- 
pressed, makes  a  pad  three-quarters  of  an  inch  in  thick- 
ness. A  plaster-of-Paris  bandage  is  applied  to  the  foot 
and  leg,  and  extends  above  the  knee,  and  care  should 
be  taken  to  apply  additional  turns  about  the  sole  of  the 
foot  and  ankle,  to  give  it  greater  strength  at  these  points. 
The  turns  of  the  bandage  should  also  be  firmly  applied 
about  the  expanded  head  of  the  tibia. 


FRACTURES  OF  THE  FIBULA.  401 

In  the  ambulatory  met  hod  of  treatment,  the  patient,  as 
.soon  as  the  bandage  lias  become  firm,  is  allowed  to  walk 
about,  first  with  crutches  or  a  cane,  and  finally  bearing 
his  weight  upon  the  injured  limb. 

Fractures  of  the  Fibula.— In  fractures  of  the  fibula, 
with  the  exception  of  that  fracture  occurring  at  the  lower 
end  of  the  bone,  the  deformity  is  not  marked,  and  they 
are  usually  dressed  with  a  fracture-box  applied  as  in  the 
dressing  of  fractures  of  both  bones  of  the  leg,  and  at  the 
end  of  two  weeks  a  plaster-of-Paris  dressing  should  be 
applied,  and  the  patient  allowed  to  get  out  of  bed  and 
move  about  on  crutches.  The  union  in  a  fracture  of  the 
fibula  is  usually  quite  firm  at  the  end  of  five  weeks,  at 
which  time  all  dressings  may  be  dispensed  with. 

Fracture  of  the  Lower  End  of  the  Fibula  (Pott's  Fract- 
ure).— This  fracture  usually  occurs  in  the  lower  fifth  of 
the  bone,  and  is  often  associated  with  laceration  of  the 
internal  lateral  ligament  of  the  ankle-joint  or  a  sprain- 
fracture  of  the  internal  malleolus,  and  is  usually  accom- 
panied by  marked  e version  of  the  foot. 

Treatment. — After  reducing  the  displacement  by  exten- 
sion and  manipulation,  the  limb  should  be  placed  in  a 
fracture-box  provided  with  a  soft  pillow,  the  foot  should 
be  secured  to  the  footboard,  and  a  pad  of  oakum  or  cotton 
should  be  placed  under  the  tendo-Achillis  :  before  bring- 
ing up  the  sides  of  the  box  and  securing  them,  two  firm 
compresses  of  lint  or  oakum  should  be  placed  in  contact 
with  the  leg  and  foot,  one  just  above  the  inner  malleolus, 
the  other  just  below  the  outer  malleolus.  The  sides  of 
the  box  are  next  brought  up  and  secured,  and  by  the 
pressure  of  these  compresses  the  foot  is  brought  into  an 
inverted  position  and  the  deformity  is  corrected. 

The  after-dressing  of  this  fracture  consists  in  letting 
down  the  sides  of  the  box,  and  in  inspecting  the  parts  to 
see  that  the  foot  is  kept  in  the  proper  position,  and  care 
should  be  taken  that  undue  pressure  is  not  made  upon  the 
skin  by  the  compresses,  which  might  result  in  ulceration  ; 
this  may  be  avoided  by  sponging  the  skin  with  alcohol 
and  changing  the  positions  of  the  compresses  slightly  at 

26 


402 


FRACTURES. 


each  dressing.  At  the  expiration  of  ten  days  the  fract- 
ure-box and  compresses  may  be  removed  and  the  limb 
put  up  in  a  plaster-of- Paris  dressing,  including  the  foot 
and  leg,  up  to  the  knee.  The  patient  may  then  be  allowed 
to  go  about  on  crutches,  and  at  the  end  of  five  weeks  all 
dressings  may  be  dispensed  with. 

This  fracture  may  also  be  treated  by  the  forcible  cor- 
rection of  the  deformity  under  ether  and  the  immediate 
application  of  a  plaster-of-Paris  dressing. 

Dupuytren's  splint,  which  consists  of  a  straight  wooden 
splint  long  enough  to  extend  from  the  condyles  of  the 
femur  to  the  end  of  the  toes,  may  also  be  employed  ; 
this  splint  is  provided  with  padding,  the  thickest  part  of 
which,  several  inches  in  thickness,  should  rest  upon  the 
skin  just  above  the  inner  malleolus  when  the  splint   is 

Fig.  300. 


Dupuytren's  splint  applied. 


applied  to  the  inner  side  of  the  leg.  The  splint  is  secured 
in  position  by  the  turns  of  a  roller  applied  over  the  foot 
and  at  the  upper  part  of  the  leg  (Fig.  300).  After  using 
this  dressing  for  a  few  days,  if  the  displacement  is  satis- 
factorily corrected,  the  splint  may  be  removed  and  the  leg 
placed  in  a  fracture-box  or  in  a  plaster-of-Paris  dressing. 

Fractures  of  the  Tarsal  Bones. — The  calcaneum  and 
astragalus  are  the  tarsal  bones  most  frequently  fractured. 

Treatment. — The  dressing  of  fractures  of  the  calca- 
neum, after  reducing  the  displacement,  which  is  not 
usually  marked  unless  the  posterior  portion  of  the  bone 
is  involved,  by  manipulation,  consists  in  placing  the 
leg  and  foot  in  a  fractu re-box,  care  being  taken  that 
the    foot   is    kept   at   a  right  angle    to   the   leg.     When 


FRACTURES  OF  THE  PHALANGES  OF  THE  TOES.    403 

the  fracture  involves  the  posterior  portion  of  the  bone, 
and  there  is  displacement  by  the  action  of  the  muscles 
inserted  into  the  fragment,  the  leg  should  be  flexed  upon 
the  thigh  and  the  foot  extended  ;  this  position  may  be 
maintained  by  applying  a  well-padded  curved  splint  to  the 
anterior  portion  of  the  leg  and  foot  and  securing  it  in 
position  by  a  bandage. 

Fractures  of  the  astragalus,  after  reducing  any  defor- 
mity which  is  present  by  extension  and  manipulation,  are 
dressed  by  placing  the  foot  and  leg  in  a  fracture-box,  care 
being  taken  that  the  foot  is  kept  at  a  right  angle  to  the 
leg.  This  precaution  is  important,  as  anchylosis  not  in- 
frequently occurs  after  this  fracture,  and  if  the  foot  is  in 
the  proper  position  it  is  much  more  useful  to  the  patient. 

As  soon  as  the  swelling,  which  is  usually  very  marked 
after  fracture  of  the  calcaneum  or  astragalus,  subsides,  the 
foot  and  leg  should  be  put  up  in  a  plaster-of- Paris  band- 
age. The  amount  of  tension  and  the  inability  to  reduce 
the  displacement  in  cases  of  fracture  of  the  astragalus  may 
be  indications  for  excision  of  the  fractured  bone.  The 
time  required  for  union  in  fractures  of  the  tarsal  bones  is 
from  five  to  six  weeks. 

Fractures  of  the  Metatarsal  Bones. — These  fractures 
are  dressed  by  placing  the  foot  upon  a  well-padded  plantar 
splint,  and  using  compresses  to  hold  the  fragments  in  place 
if  there  is  much  displacement,  the  splint  and  compresses 
being  held  in  position  by  a  bandage  ;  or  they  may  be 
treated  by  placing  the  foot  and  leg  in  a  fracture-box,  the 
footboard  of  the  box  acting  as  a  plantar  splint ;  the  plaster- 
of-Paris  dressing  may  also  be  used  in  these  cases.  The 
time  required  for  union  in  fracture  of  the  metatarsal  bones 
is  from  three  to  four  weeks. 

Fractures  of  the  Phalanges  of  the  Toes. — These  fract- 
ures are  often  compound  and  attended  with  so  much 
laceration  of  the  soft  parts  that  immediate  amputation  is 
required ;  when,  however,  the  fractures  are  simple,  or  in 
compound  fractures  where  amputation  is  not  required,  the 
dressing  consists  in  applying  a  plantar  splint  of  wood  or 
binders'  board,  extending  beyond  the  toes  and  securing  it 


404  FRACTURES. 

in  position  by  the  turns  of  a  roller-bandage.  When  a 
single  toe  only  is  broken,  a  moulded  splint  of  gutta-percha 
or  binders'  board  may  be  applied,  and  a  portion  of  the 
splint  should  extend  some  distance  upon  the  sole  of  the 
foot,  to  fix  the  proximal  joint,  and  also  to  give  the  toe  a 
firm  point  of  fixation  ;  the  moulded  splint  should  be  held 
in  position  by  a  narrow  roller-bandage  or  by  strips  of  ad- 
hesive plaster.  The  time  required  for  union  in  fractures 
of  the  phalanges  of  the  toes  is  about  three  weeks. 


COMPOUND  OR  OPEN  FRACTURES. 

In  the  dressing  of  compound  or  open  fractures  the  same 
dressings  and  splints  which  are  generally  used  in  the  treat- 
ment of  simple  or  closed  fractures  may  be  employed ;  the 
wound  in  the  soft  parts  requires  a  special  dressing,  and  this 
should  be  so  arranged  as  to  secure  free  drainage  and  pro- 
mote its  prompt  healing.  In  some  cases  of  compound 
fracture  the  treatment  of  the  injuries  of  the  soft  parts 
demands  attention  first,  and  in  such  cases  the  injury  to  the 
bones  is  for  a  time  disregarded,  care  being  taken  that 
the  fragments  are  kept  quiet,  so  as  to  prevent  further 
damage  to  the  soft  parts  until  the  wound  is  in  such  a 
condition  that  the  proper  manipulation  to  reduce  the  dis- 
placement and  fix  the  fragments  by  splints  and  suitable 
dressings  may  be  undertaken  without  interfering  with  the 
repair  of  the  wound. 

Treatment. — In  the  dressing  of  compound  or  open 
fractures  the  skin  surrounding  the  wound  should  first  be 
carefully  cleansed,  and  the  wound  next  be  thoroughly  irri- 
gated with  a  1  :  2000  bichloride  solution,  and  any  foreign 
bodies  or  loose  fragments  of  bone  removed  ;  if  there  is 
hemorrhage,  it  should  be  controlled  by  securing  the  bleed- 
ins;  vessels  with  ligatures.  The  reduction  of  the  dis- 
placement  should  next  be  accomplished  by  making  ex- 
tension and  by  manipulation  ;  if  the  fragments  project 
from  the  wound,  before  this  can  be  satisfactorily  accom- 
plished it  may  be  necessary    to   enlarge  the  wound  and 


COMPOUND   OR  OPEN  FRACTURES.  405 

to  resect  one  or  both  ends  of  the  fractured  bones,  and 
in  some  cases  it  may  be  necessary  to  drill  the  ends  of 
the  fragments  and  introduce  a  strong  wire  or  catgut 
suture,  or  a  metallic  nail,  screw,  or  plate,  to  hold  them  in 
their  proper  positions.  After  reduction  of  the  displace- 
ment the  Avound  should  again  be  thoroughly  irrigated  with 
an  antiseptic  or  normal  salt  solution,  and  after  making 
provision  for  drainage  by  the  introduction  of  a  drainage- 
tube  or  tubes,  counter-openings  being  made  to  secure  free 
drainage  if  necessary,  sterilized  or  antiseptic  gauze  dress- 
ings should  be  applied. 

The  wound,  if  a  small  one,  need  not  be  closed  with 
sutures ;  but  if  extensive,  a  few  catgut,  silk,  or  silkworm- 
gut  sutures  may  be  applied  to  bring  the  edges  of  the  wound 
into  apposition,  care  being  taken  to  avoid  making  undue 
tension ;  if  the  soft  parts  have  been  much  lacerated  or 
contused,  it  is  better  to  introduce  no  sutures.  If  the 
limb  is  much  swollen  and  the  Avound  is  a  small  one,  free 
division  of  the  deep  fascia  to  relieve  tension  and  secure 
drainage  is  often  followed  by  good  results.  A  final  irri- 
gation of  the  Avound  through  the  drainage-tube  is  next 
made,  and  the  Avound  is  covered  by  a  bichloride  gauze 
dressing  and  a  number  of  layers  of  bichloride  cotton,  the 
Avhole  dressing  being  held  in  position  by  a  gauze  bandage 
applied  Avith  moderate  firmness. 

The  reduction  of  the  fragments  and  the  dressing  of 
the  Avound  having  been  accomplished  as  described,  the 
splints  appropriate  for  a  similar  fracture,  if  it  Avere  a 
simple  or  closed  one,  are  next  applied.  If  the  surgeon 
has  been  able  to  render  the  Avound  aseptic,  and  has  applied 
an  antiseptic  dressing,  the  compound  fracture  is  often 
soon  converted  into  a  simple  one  by  the  prompt  healing 
of  the  wound,  and  the  patient  may  exhibit  no  more 
constitutional  disturbance  than  he  would  have  with  a 
similar  simple  or  closed  fracture.  The  redressing  of  a 
compound  fracture  dressed  in  this  Avay  need  not  be  made 
for  a  Aveek  or  ten  days,  unless  there  is  a  rise  in  the 
patient's  temperature  or  the  dressings  become  soaked  with 
discharges  from  the  Avound,  or  they  become  uncomfortable 


406 


FRACTURES. 


to  the  patient  by  reason  of  swelling  of  the  soft  parts  in 
the  region  of  the  wound.  When  redressing  of  the  fract- 
ure becomes  necessary  the  dressings  are  removed,  and  the 
drainage-tubes  may  also  be  removed  if  no  longer  needed ; 
the  wound  being  redressed  with  an  antiseptic  or  aseptic 
dressing,  the  splints  are  reapplied,  and,  after  the  wound  is 
healed,  the  subsequent  dressing  of  the  fracture  should  be 
the  same  as  that  of  a  simple  fracture.  The  time  required 
for  union  a  compound  fracture  is  usually  much  longer 
than  in  a  corresponding  simple  fracture. 

Plaster-of-Paris  Dressing. — This  may  be  used  as  a  primary 
dressing  in  compound  fractures;  the  displacement  being 


Fig.  301. 


Fenestrated  plaster  dressing  for  compound  fracture  of  the  leg.     (Stimson.) 

reduced  and  the  wound  dressed  with  an  antiseptic  gauze 
dressing,  a  plaster-of-Paris  bandage  is  applied  to  the  parts 
so  as  firmly  to  fix  the  fragments ;  the  joints  on  either  side 
of  the  fracture  should  be  fixed  by  the  bandage,  and  the 
parts  should  be  held  in  position  until  the  plaster  has  set 
firmly.  After  the  plaster  has  become  firm  a  fenestrum 
should  be  made  over  the  position  of  the  wound,  so  that  it 
may  be  inspected  or  dressed  through  this  when  necessary. 
The  ends  of  a  piece  of  stout  wire,  bent  into  a  semicircle, 
may  be  incorporated  in  the  turns  of  the  plaster  bandage 
above  and  below  the  position  of  the  fenestrum,  to  give  it 


COMPOUND   OR   OPEN  FRACTURES.  407 

additional  strength  after  the  removal  of  a  portion  of  the 
bandage  to  make  the  fenestrnm  (Fig.  301). 

If  the  plaster-of- Paris  dressing  is  applied  as  a  primary 
dressing  in  compound  fractures,  the  case  should  be  carefully 
watched  for  a  few  days,  and  if  much  swelling  occurs  at  the 
seat  of  fracture  its  removal  and  renewal  are  indicated  ; 
profuse  discharge  of  serum  may  also  soak  the  dressings 
and  bandage,  so  that  its  renewal  is  necessitated.  Some 
surgeons,  therefore,  prefer  to  defer  the  application  of  the 
plaster-of-Paris  dressing  in  compound  fractures  for  a  few 
weeks  until  the  swelling  has  diminished  and  the  wound  is 
nearly  or  quite  healed  ;  the  wound  being  covered  with  an 
antiseptic  dressing,  the  plaster  bandage  is  applied,  and  a 
fenestrum  is  made  over  the  position  of  the  wound  if 
required. 

Binders'  Board  or  Felt  Splints. — These  may  also  be  em- 
ployed in  the  dressing  of  compound  fractures,  being 
moulded  to  the  parts  after  an  antiseptic  dressing  has  been 
applied  to  the  wxmnd,  and  held  in  position  by  the  turns 
of  a  roller-bandage. 

The  principal  advantage  in  the  use  of  these  splints  is 
the  ease  with  which  they  can  be  removed  and  reapplied  if 
frequent  dressings  of  the  fracture  are  necessary  for  any 
reason.  They  may  be  used  during  the  entire  course  of 
treatment ;  or,  after  a  few  weeks,  when  the  swelling  has 
diminished  at  the  seat  of  fracture  and  the  wound  is  well 
advanced  toward  repair,  they  may  be  discarded  and  a 
plaster-of-Paris  dressing  substituted.  In  compound  fract- 
ures of  the  bones  of  the  leg,  after  reducing  the  displace- 
ment and  applying  an  antiseptic  dressing  to  the  wound,  I 
usually  apply  moulded  binders'  board  splints  to  either  side 
of  the  leg,  including  the  foot,  and  place  the  leg  in  a  fract- 
ure-box for  additional  security,  and  after  a  week  or  ten 
days  I  discard  the  binders'  board  splints  and  apply  a  plas- 
ter-of-Paris dressing. 

A  method  of  dressing  compound  fractures  which  has 
been  introduced  by  Mr.  Treves  consists  in  rendering  the 
skin  in  the  region  of  the  wound  aseptic  and  removing  any 
foreign  bodies  from  the  wound,  then  rendering  it  as  far 


408 


FRACTURES. 


as  possible  aseptic ;  powdered  iodoform  is  then  dusted 
thickly  over  the  wound  at  intervals,  and,  mixing  with  the 
blood  and  serum  from  the  wound,  is  allowed  to  dry,  form- 
ing an  antiseptic  scab,  the  wound  being  exposed  to  the  air, 
and  the  fragments  are  retained  in  position  by  splints  or  by 
a  fracture-box. 

UNUNITED  FRACTURE. 

This  condition  usually  arises  from  local  causes,  such 
as  imperfect  coaptation  of  the  fragments,  the  interpo- 
sition of  muscular  tissue,  fascia,  a  tendon,  or  nerve,   or 


Fig.  302. 


Fig.  303. 


Fragments  in  ununited  fracture 
secured  by  silver  wire. 


Fragments  in  ununited  fracture 
secured  by  silver  splint. 


a  portion  of  devitalized  bone  between  the  fragments.  The 
ends  of  the  bones  may  be  rounded,  or  may  be  united  by 
fibrous  tissue,  or  there  may  be  an  attempt  at  the  forma- 
tion of  a  false-joint,  the  end  of  one  fragment  being  rounded 
off  and  the  other  cupped  to  receive  it. 


UNUNITED  FRACTURES.  409 

Treatment. — This  consists  in  exposing  the  ends  of  the 
bones  by  incision,  with  full  antiseptic  precautions,  and 
removing  the  ends  of  the  bones  to  secure  a  healthy  sur- 
face, and  then  fixing  the  bones  securely  together  by  drill- 
ing them  and  introducing  one  or  more  heavy  silver-wire 
sutures  (Fig.  302).  In  some  cases  the  shape  of  the 
fragments  is  such  that  they  can  be  sawed  so  as  to  form  a 
mortise,  and  the  bones  can  then  be  fixed  by  the  intro- 
duction of  one  or  more  steel  or  silver  screws.  Another 
method  of  fixation  is  by  a  steel  or  silver  splint  secured  to 
the  fragments  by  iron  or  silver  screws  (Fig.  303).  After 
the  fixation  of  the  bones  has  been  accomplished,  the  wound 
should  be  closed  and  an  antiseptic  dressing  applied ;  ad- 
ditional fixation  is  furnished  by  the  application  of  a 
plaster-of- Paris  dressing. 


PAET    IV. 

DISLOCATIONS. 


Dislocation. — This  consists  in  displacement  of  the  ar- 
ticular surfaces  of  the  bones  which  enter  into  the  forma- 
tion of  a  joint.  Dislocations  may  be  complete,  partial, 
simple,  compound,  and  complicated,  and  they  are  also 
known  as  habitual  recent  and  old  dislocations. 

Complete  Dislocation. — This  is  a  dislocation  in  which 
no  portions  of  the  articular  surfaces  of  the  bones  remain 
in  contact  with  each  other. 

Partial  Dislocation. — This  is  a  dislocation  in  which  por- 
tions of  the  articular  surfaces  of  the  bones  still  remain  in 
contact  with  each  other. 

Simple  Dislocation. — This  is  a  dislocation  in  which 
there  exists  displacement  in  the  relation  of  the  articular 
surfaces  of  the  bones  with  little  injury  to  the  soft  parts 
adjacent  to  the  joint,  and  the  displaced  ends  of  the  bones 
do  not  communicate  with  the  air  by  a  wound  in  the  soft 
parts. 

Compound  Dislocation. — This  is  a  dislocation  in  which 
there  exists  displacement  of  the  articular  surfaces  of  the 
bones  which  communicate  with  the  air  through  a  wound 
in  the  soft  parts. 

Complicated  Dislocation. — This  is  a  dislocation  in  which, 
in  addition  to  the  displacement  of  the  articular  surfaces 
of  the  bones,  there  exists  a  fracture,  or  a  laceration  of 
important  bloodvessels,  nerves,  or  muscles  in  connection 
with  the  dislocation. 

411 


412  DISLOCATIONS. 

Habitual  Dislocation. — Tins  consists  in  a  dislocation 
which  constantly  recurs  upon  slight  provocation,  and  is 
usually  due  to  a  relaxed  condition  of  the  ligaments  of 
the  joint. 

Recent  Dislocation. — This  is  a  dislocation  in  which  the 
displacement  of  the  articulating  surfaces  of  the  bones  has 
existed  for  such  a  period  that  time  has  not  been  afforded 
for  inflammatory  changes  to  take  place  in  the  articular 
surfaces  of  the  bones  or  in  the  adjacent  tissues  which 
would  seriously  interfere  with  their  reduction. 

Old  Dislocation. — This  is  a  dislocation  in  which  the 
displacement  of  the  articulating  surfaces  of  the  bones  has 
existed  for  some  time  :  in  this  variety  of  dislocation  the 
displaced  bones  often  form  firm  adhesions  to  the  surround- 
ing tissues,  and  the  articulating  surfaces  often  undergo 
changes. 

Treatment  of  Dislocations. — The  first  indication  in 
the  treatment  of  dislocations  is  to  return  the  displaced 
articular  surfaces  of  the  bones  to  their  normal  position, 
and  to  retain  them  in  this  position  by  the  use  of  suitable 
dressings.  The  return  of  the  articular  surfaces  of  the 
bones  to  their  normal  position,  or  the  reduction  of  the  dis- 
location, is  accomplished  by  manipulation,  extension,  and 
counter-extension.  The  reduction  of  dislocations  should 
be  attempted  as  soon  as  possible  after  they  have  occurred. 

The  principal  obstacles  to  the  reduction  of  dislocations 
are  muscular  resistance  and  the  anatomical  peculiarities 
of  the  joints.  The  former  is  best  overcome  by  the  use 
of  an  ancesthetle  given  to  the  point  where  complete  mus- 
cular relaxation  is  produced.  The  resistance  offered  by 
the  changed  relations  of  the  articular  surfaces  and  the 
ligaments  is  to  be  overcome  by  the  surgeon  making  such 
manipulations,  founded  upon  his  knowledge  of  the  anat- 
omy of  the  parts,  as  will  make  the  ligaments,  muscles,  and 
bones  assist  in  the  reduction  of  the  dislocation. 

In  recent  dislocations,  by  the  use  of  extension  and 
manipulation,  especially  if  an  anaesthetic  be  employed, 
the  reduction  is  usually  accomplished  without  the  use  of 
much  force;  but  in  old  dislocations,  where  absolute  mus- 


SPECIA  L  DISLOCATIONS. 


413 


cular  shortening  lias  taken  place,  the  use  of  extending 
bands  is  often  required,  and  in  securing  these  bands  to  the 
limb  the  clove-hitch  knot  is  useful  (Fig.  304). 

The  treatment  of  dislocations  after  reduction  consists 
in  placing  the  joint  at  complete  rest  by  the  application  of 
suitable  splints  and  bandages,  and  in  treating  any  inflam- 
matory complications,  if  they  arise,  by  the  application  of 

Fig.  o04. 


Clove-hitch  knot  applied.    (Erichsen.) 


evaporating  lotions,  and  in  a  week  or  two,  after  the  injured 
ligaments  have  been  repaired,  passive  motion  should  be 
resorted  to  for  restoring  the  function  of  the  joint. 


SPECIAL    DISLOCATIONS. 

Dislocations  of  the  Vertebrae. — Dislocations  of  the 
lumbar  and  dorsal  vertebrce,  as  simple  dislocations,  are  ex- 
tremely rare  accidents  ;  they  are  occasionally  met  with,  but 
are  more  often  associated  with  fractures  of  the  vertebrae  in 
these  regions.  Uncomplicated  dislocations  of  the  cervical 
vertebras  are  more  common.  The  treatment  of  dislocations 
of  the  vertebra?,  whether  complicated  with  fracture  or  not, 
consists  in  attempting  reduction  by  making  extension  and 
counter-extension  with  manipulation,  and  by  this  means, 
in  many  cases,  the  luxations  may  be  reduced.  If,  however, 
the  efforts  at  reduction  are  unsuccessful,  permanent  exten- 
sion should  be  applied  by  means  of  a  weight  extension 


414 


DISLOCATIONS. 


apparatus  from  both  legs  and  from  the  shoulders  and 
head.  The  after-treatment  consists  in  keeping  the  patient 
at  rest  upon  his  back  in  bed  upon  a  firm  mattress,  and  if 
the  cervical  vertebrae  have  been  involved,  the  head  and 
neck  should  be  supported  by  short  sand  bags ;  and  in  case 
of  the  vertebrae  below  this  point,  the  application  of  a 
plaster-of- Paris  jacket  may  be  used  to  give  support  and 
fixation  to  the  part.  The  general  management  of  the 
case  as  regards  complications  is  similar  to  that  in  cases  of 
fracture  of  the  vertebrae. 

Dislocations  of  the  Coccyx. — These  are  reduced  by 
manipulations  with  the  finger  in  the  rectum  and  external 
manipulation  at  the  same  time.  The  only  after-treatment 
required  is  rest  in  bed  for  a  few  days  and  the  administra- 
tion of  opium  to  keep  the  bowels  quiet. 

Fig.  305. 


Bilateral  dislocation  of  the  lower  jaw.    (Ashhurst.) 

Dislocations  of  the  Lower  Jaw. — These  dislocations 
may  consist  in  the  displacement  of  one  or  both  condyles 


DISLOCATIONS  OF  RIBS  AND  COSTAL  CARTILAGES.   415 


of  the  lower  jaw  from  the  glenoid  fossae,  constituting  the 
unilateral  or  bilateral  dislocation  of  the  jaw  ;  the  latter  is 
the  more  common  form  of  dislocation  of  the  jaw  met  with, 
and  the  deformity  resulting  is  shown  in  Fig.  305. 

The  reduction  of  a  dislocation  of  the  lower  jaw  is  accom- 
plished as  follows  :  The  surgeon  placing  his  thumbs,  well 
protected  by  strips  of  bandage  or  a  towel,  on  the  molar 
teeth  or  behind  them,  presses  the  angles  of  the  jaw  down- 
ward while  he  elevates  the  chin  with  his  fingers,  and  by 
this  manipulation  the  condyles  of  the  jaw  usually  slip  back 
into  place  with  a  snap  (Fig.  306).     After  reduction  of  the 

Fig.  306. 


Method  of  reducing  dislocation  of  the  lower  jaw.    (Hajiilton.) 

dislocation  the  jaw  should  be  fixed  for  a  week  or  ten  days 
by  the  application  of  a  Barton's  bandage  or  a  four-tailed 
sling. 

Dislocation  of  the  Hyoid  Bone. — A  few  cases  of  dis- 
location of  the  hyoid  bone  have  been  recorded ;  the  treat- 
ment consists  in  throwing  back  the  head  as  far  as  possible, 
to  place  the  muscles  of  the  neck  upon  the  stretch,  depress- 
ing the  lower  jaw,  and  pressing  the  luxated  bone  into 
position. 

Dislocations  of  the  Ribs  and  Costal  Cartilages.— 
The  ribs  may  be  dislocated  at  their  vertebral  articulations 
or  at  the  junction  with  the  costal  cartilages,  or  the  carti- 
lages may  be  separated  from  the  sternum.  These  injuries 
result  from  the  application   of  great  force,  and  are  often 


416  DISLOCA  TIONS. 

fatal  from  associated  injuries  of  the  thoracic  viscera. 
The  treatment  of  these  dislocations  consists  in  reducing 
the  displacement  by  manipulation  and  pressure,  and  then 
in  fixing  the  chest  to  secure  immobility  of  the  ribs  by 
strapping  the  affected  side  with  strips  of  adhesive  plaster, 
the  same  dressing  being  applied  as  in  cases  of  fracture 
of  the  ribs,  the  dressing  being  retained  for  three  or  four 
weeks. 

Dislocations  of  the  Sternum. — Dislocation  or  diastasis 
of  the  sternum  may  occur  at  the  junction  of  the  manu- 
brium and  the  gladiolus  or  at  the  junction  of  the  ensiform 
cartilage  and  the  gladiolus.  The  reduction  is  effected  by 
extension  of  the  chest  by  bending  the  dorsal  spine  over  a 
firm  cushion  placed  under  the  back  and  by  pressure  upon 
the  projecting  bone ;  when  the  displaced  bone  has  been 
reduced,  a  compress  should  be  placed  over  the  seat  of  in- 
jury, and  held  in  place  by  broad  strips  of  adhesive  plaster, 
or  by  a  bandage  to  keep  the  parts  at  rest.  The  dressing 
should  be  retained  for  three  or  four  weeks. 

In  the  few  examples  of  dislocation  of  the  ensiform 
cartilage  which  have  been  reported,  the  displacement  of 
the  cartilage  has  in  some  cases  given  rise  to  persistent 
vomiting,  which  was  relieved  by  reduction  of  the  displace- 
ment ;  it  is,  however,  almost  impossible  to  keep  the  bone 
in  place  after  reduction. 

Dislocations  of  the  Pelvis. — Dislocation  or  diastasis 
of  the  bones  of  the  pelvis  may  occur  at  the  pubic  or 
sacro-iliac  symphyses.  They  are  generally  serious  in- 
juries, as  they  are  apt  to  be  complicated  by  lesions  of  the 
pelvic  viscera. 

The  reduction  of  these  dislocations  is  effected  by  press- 
ure and  manipulation,  and  after  reduction  the  parts  should 
be  supported  by  a  compress  held  in  place  by  a  stout  binder 
or  by  broad  strips  of  adhesive  plaster,  the  patient  being 
kept  quiet  in  bed  and  the  pelvis  being  supported  by  means 
of  sand  bags.  The  dressings  should  be  retained  for  from 
four  to  six  weeks. 

Dislocations  of  the  Clavicle. — Dislocations  of  the  clav- 
icle may  occur  either  at  the  sternal  or  acromial  end ;  the 


DISLOCATIONS  OF  THE  CLAVICLE.  417 

latter  injury  some  writers  describe  as  a  dislocation  of  the 
scapula,  following  the  general  rule  that  the  distal  bone  is 
the  one  dislocated. 

Dislocations  of  the  Sternal  End  of  the  Clavicle. These 

may  occur  in  a  forward,  backward,  or  upward  direction 
and  the  displacement  is  generally  well  marked  (Fig.  307)! 
The  reduction  of  this  dislocation  is  effected  by  placing  the 
knee  against  the  spine,  and  drawing  the  shoulders  outward 
and  backward  and  pressing  the  displaced  end  of  the  clav- 
icle into  place.  The  reduction  is  generally  easy,  but  it  is 
often  difficult  to  keep  the  end  of  the  bone  in  its  proper 
position.  To  accomplish  this,  a  compress  should  be  placed 
over  the  end  of  the  bone,  and  this  should  be  secured  in 
place  by  broad  strips  of  adhesive  plaster ;  the  shoulders 
should  be  brought  well  backward  and  secured  bv  a  pos- 
terior figure-of-eight  bandage  of  the  chest,  and  the  arm 
of  the  injured  side  should  be  fastened  to  the  side  of  the 
chest  by  spiral  turns  of  a  bandage.  In  some  cases,  in 
addition  to  the  compress  over  the  end  of  the  bone,  secur- 
ing the  arm  of  the  injured  side  in  the  Yelpeau  position 
will  be  found  all  that  is  necessary  to  retain  the  bone  in 
position. 

Dislocation  of  the  Acromial  End  of  the   Clavicle. This 

may  be  upward,  downward,  or  backward  (Fig.  308). 
The  reduction  is  effected  by  manipulation  of  the  arm  and 
scapula  and  by  pressure  over  the  displaced  end  of  the 
clavicle.  The  displacement  is  usually  reduced  without 
much  trouble,  but  it  is  often  a  matter  of  difficulty  to  keep 
the  end  of  the  bone  in  its  proper  place.  The  dressing 
consists  in  placing  a  compress  over  the  acromial  end  of 
the  clavicle  and  holding  it  in  place  by  broad  slips  of 
adhesive  plaster  ;  the  arm  should  at  the  same  time  be 
fixed  in  the  Velpeau   position. 

Stimson's  dressing  consists  in  applying  a  long  strip  of 
adhesive  plaster  three  inches  wide,  the  centre  being  placed 
over  the  flexed  elbow  and  its  ends  carried  up  in  front  of 
and  behind  the  arm,  crossing  over  the  end  of  the  clavicle 
and  being  secured  on  the  front  and  back  of  the  chest, 
respectively,  while  the  bone  is  held  in  place  by  pressure 

27 


418 


DISLOCATIONS. 


upon  the  clavicle  and  the  elbow.  For  additional  security, 
the  forearm  may  be  supported  in  a  sling  and  the  arm 
bound  to  the  side  of  the  chest. 

The  dressings  after  reduction  of  dislocations  of  the 
clavicle  should  be  kept  in  place  for  at  least  three  weeks. 
Although  in  many  cases  a  certain  amount  of  deformity 
persists,  the  disability  resulting  from  the  injury  is  not 
often  marked. 


Fig.  307. 


Fig.  308. 


Dislocation  of  sternal  end  of  clavicle 
forward.     (Bryant.) 


Dislocation  of  clavicle  at  acromial 
end.    (Bryant.) 


Dislocations  of  the  Scapula. — Dislocation  of  the  acro- 
mion process  of  the  scapula  from  the  outer  end  of  the 
clavicle,  which  has  been  described  under  dislocations  of 
the  acromial  end  of  the  clavicle,  is  classed  by  some  writers 
as  a  scapular  dislocation. 

Dislocation  of  the  Inferior  Angle  of  the  Scapula. — The 
displacement  of  the  inferior  angle  of  the  scapula  from 
under  the  latissimus  dorsi  muscle  is  due  to  relaxation 
of  this  muscle  and  of  the  serratus  magnus,  and  is  some- 
times described  as  a  dislocation  of  the  inferior  angle  of 
the  scapula.  The  reduction  of  this  deformity  consists  in 
the  employment  of  manipulation  and  pressure  to  over- 
come the  displacement,  and  the  use  of  a  compress  held 
in  place  by  broad  strips  of  adhesive  plaster  to  secure  the 
bone  in  its  proper  position. 


DISLOCATIONS   OF   THE  SHOULDER 


419 


Dislocations  of  the  Shoulder. — The  head  of  the 
humerus  niav  be  dislocated  downward,  forward,  or  bach- 
ward. 

Subglenoid  Dislocation  of  the  Head  of  the  Humerus. — In 

this   varietv  of  dislocation  the   head  of  the  hone  rests  in 

the  axilla  (Fig.  309). 

Fig.  309. 


Subglenoid  dislocation  of  the  head  of  the  humerus.    (Stdbson.) 


Subcoracoid  Dislocation  of  the  Head  of  the  Humerus. — 
Tn  this  varietv  of  dislocation  the  head  of  the  humerus 
rests  beneath  the  coracoid  process  of  the  scapula  (Fig. 
310). 

Subclavicular  Dislocation  of  the  Head  of  the  Humerus. — 
This  may  be  considered  an  aggravated  form  of  the  latter 
variety  of  dislocation  ;  the  head  of  the  humerus  in  this 
dislocation  rests  beneath  the  clavicle. 


420 


DISLOCATIONS. 


Subspinous  Dislocation  of  the  Head  of  the  Humerus. — In 
this  variety  of  dislocation  the  head  of  the  humerus  rests 
beneath  the  spine  of  the  scapula  (Fig.  311). 

Reduction  of  dislocations  of  the  humerus  is  effected  by 
manipulation,  by  extension  and  counter-extension,  and  by 
a  combination  of  these  methods. 

Manipulation  in  the  reduction  of  subglenoid  dislocation 
of  the  humerus  is  practised  with  the  patient  in  the  recum- 
bent posture  by  first  flexing  the  forearm  upon  the  arm  to 


Fig.  310. 


Subcoracoid  dislocation  of  the  head  of  the  humerus.    (Stimson.) 

relax  the  long  head  of  the  biceps  muscle ;  the  elbow  is 
next  seized  and  abducted  so  as  to  bring  it  to  the  side  of 
the  patient's  head,  thus  relaxing  the  deltoid  and  supra- 
spinatus  muscles ;  the  surgeon  or  an  assistant  next  places 
his  hand  upon  the  head  of  the  humerus  in  the  axilla,  and, 
as  the  arm  is  drawn  outward  to  a  right  angle  with  the 


DISLOCATIONS  OF  THE  SHOULDER. 


421 


body  by  the  other  hand,  he  pushes  the  head  of  the  bone 
into  the  glenoid  cavity. 

In  the  reduction  of  subeoracoid  and  subclavicular  dislo- 
cations the  manipulations  are  the  same,  except  that  the  arm 
is  to  be  rotated  outward  before  being  carried  downward. 

In  the  reduction  of  subspinous  dislocations,  after  the  arm 
has  been  abducted,  it  should  be  rotated  inward  and  direct 
pressure  made  upon  the  head  of  the  bone  as  the  arm  is 
abducted. 

Fig.  311. 


Subspinous  dislocation  of  the  head  of  the  humerus.    (Erichsen.) 

Reduction  may  also  be  effected  by  extension  and  counter- 
extension,  as  in  Cooper's  method,  where  extension  is  made 
from  the  arm  downward  and  counter-extension  is  made  by 
the  heel  in  the  axilla  (Fig.  312).  This  method  is  not  to 
be  recommended,  on  account  of  the  damage  which  may 
occur  to  the  axillary  nerves  and  vessels. 

Kocher's  method  of  reduction  of  dislocations  of  the  shoul- 
der consists  in  flexing  the  elbow  at  a  right  angle  and  press- 
ing it  closely  against  the  side,  the  forearm  at  the  same  time 
being  turned  as  far  as  possible  away  from  the  trunk. 
While  the  external  rotation  is  being  maintained  the  elbow 


422 


DISLOCATIONS. 
Fig.  312. 


Reduction  of  dislocation  of  the  humerus  by  heel  in  the  axilla.    (Erichsen.) 

is  carried  well  forward  and  upward,  and  the  arm  is  then 
rotated  inward  and  the  elbow  is  lowered. 

Fig.  313. 


Reduction  of  dislocation  of  the  humerus  by  extension  upward. 


Mothers  Method. — Reduction  by  this  method  may  also 
be  accomplished  by  extension  made  upward,  the  scapula 


DISLOCATIONS  OF  THE  ELBOW.  423 

being  fixed  by  the  foot  or  hand  placed  over  the  acromion 
process  (Fig.  313). 

After  reduction  of  dislocations  of  the  head  of  the 
humerus  the  arm  should  be  bound  to  the  side  of  the  body 
bv  the  turns  of  a  spiral  bandage  of  the  chest,  or  should 
be  held  against  the  side  by  the  application  of  a  Velpeau's 
bandage ;  this  dressing  should  be  removed  at  intervals  of 
a  few  days,  and  after  ten  days  or  two  weeks  all  dressings 
should  be  dispensed  with,  passive  motion  should  be  em- 
ployed, and  the  patient  allowed  to  move  the  arm. 

Dislocations  of  the  Elbow. — Dislocations  of  the  bones 
of  the  forearm  at  the  elbow  may  be  either  backward,  for- 
ward, or  lateral.  The  backward  dislocation  is  the  most 
common  form   (Fig.  314). 

Fig.  314. 


Dislocation  of  both  bones  of  the  forearm  backward.     (Liston.) 

The  reduction  of  backward  dislocations  is  effected  by 
making  traction  upon  the  forearm  and  at  the  same  time 
making  pressure  upon  the  lower  end  of  the  humerus  as 
the  forearm  is  flexed  upon  the  arm. 

Or  the  reduction  may  be  accomplished  by  bending  the 
arm  slowly  and  forcibly  over  the  knee  placed  upon  the 
inner  surface  of  the  elbow,  so  as  to  press  upon  the  radius 
and  ulna,  separating  them  from  the  humerus  and  freeing 
the  coronoid  process  from  its  abnormal  position  (Fig.  315). 

Lateral  dislocations  of  the  bones  of  the  forearm  at  the 
elbow  are  reduced  by  making  extension  from  the  forearm, 
and  at  the  same  time  making  direct  pressure  on  the  dis- 


424 


DISLOCATIONS-. 


placed  bones  and  counter-pressure  on  the  lower  end  of  the 
humerus. 

Forward  dislocations  of  the  bones  of  the  forearm  at  the 
elbow  are  reduced  by  making  forced  flexion  at  the  elbow, 
together  with  extension  and  counter-extension,  or  by  mak- 
ing forced  extension  of  the  forearm  at  the  elbow,  pressing 
the  humerus  backward,  and  suddenly  flexing  the  forearm. 

Fig.  315. 


Reduction  with  the  knee  in  the  bend  of  the  elbow.     (Hamilton.) 

The  dressing,  after  the  reduction  of  dislocations  at  the 
elbow,  consists  in  the  application  of  a  well-padded  ante- 
rior right-angled  or  slightly  obtuse-angled  splint,  to  keep 
the  forearm  in  a  flexed  position — the  dressing  being  prac- 
tically the  same  as  that  for  fractures  of  the  lower  end  of 
the  humerus,  with  an  anterior  angular  splint  (Fig.  316). 
This  dressing  should  be  retained  for  two  or  three  weeks, 
being  removed  at  intervals  of  several  days  ;  after  the  re- 


DISLOCATIONS  OF  THE  HEAD   OF  THE  RADIUS.    425 

mo  Veil  of  the  splint  passive  motion  should  be  practised,  to 
prevent  stiffness  of  the  elbow-joint. 

Fig.  316. 


Dressing  after  reduction  of  dislocation  of  the  elbow. 

Dislocations  of  the  Head  of  the  Radius. — The  head 

of  the  radius  may  be  displaced  forward,  outward,  or  back- 

Fig.  317. 


Dislocation  of  the  head  of  the  radius  forward.     iListox.) 

ward,  the  forward  dislocation  being;  the  most  frequent 
(Fig.  317).  The  reduction  of  these  dislocations  is  effected 
by  making  extension  from  the  forearm  and  counter-exten- 


426  DISLOCATIONS. 

sion  from  the  lower  end  of  the  humerus,  and  at  the  same 
time  the  head  of  the  bone  is  pressed  into  its  proper  posi- 
tion. The  dressing  after  reduction  of  the  displacements 
consists  in  the  application  of  a  compress  over  the  head  of 
the  bone,  and  the  arm  and  forearm  should  be  placed  upon 
a  well-padded  anterior  angular  splint,  which  is  secured  by 
a  roller  bandage.  The  dressing  is  similar  to  that  em- 
ployed after  reduction  of  dislocations  of  the  bones  of  the 
forearm  at  the  elbow.  Difficulty  is  sometimes  experienced 
in  keeping  the  head  of  the  bone  in  position  after  reduction, 
so  that  the  use  of  a  compress  in  addition  to  the  use  of  the 
splint  is  often  required.  The  arm  should  be  kept  upon 
the  splint  for  three  weeks,  being  redressed  at  intervals. 

Dislocation  of  the  Upper  End  of  the  Ulna. — The 
upper  end  of  the  ulna  may  be  displaced  backward,  the 
olecranon  projecting  beyond  the  condyles  of  the  humerus, 
while  the  head  of  the  radius  occupies   its  normal  position. 

The  induction  of  this  displacement  is  effected  in  the  same 
manner  as  that  of  both  bones  of  the  forearm  backward, 
and  the  dressing  after  reduction  is  similar  to  that  employed 
when  both  bones  have  been  displaced.. 

Dislocations  of  the  Wrist. — Dislocations  of  the  carpus 
from  the  bones  of  the  forearm  may  be  forward  (Fig.  318) 
or  backward  (Fig.  319).  The  reduction  in  either  variety 
of  displacement  is  effected  by  extension  from  the  hand  and 
by  pressure.  After  reduction  of  the  displacement,  which 
does  not  tend  to  recur,  the  hand  and  the  forearm  should 
be  placed  upon  a  well-padded  straight  splint  applied  to 
the  palmar  surface  of  the  hand  and  forearm.  The  splint 
should  be  retained  for  ten  days  or  two  weeks. 

The  lower  end  of  the  ulna  may  be  dislocated  from  the 
radius  forward,  backward,  or  inward.  The  reduction  of 
these  displacements  is  effected  by  fixing  the  radius  and 
pressing  the  ulna  back  into  place.  The  dressing  after 
reduction  consists  in  placing  the  wrist-joint  at  rest  by  the 
application  of  well-padded  anterior  and  posterior  straight 
splints.  The  splints  should  be  retained  for  three  or  four 
weeks,  dressings  being  made  at  intervals  of  two  or  three 
days. 


DISLOCATIONS  OF  THE  FINGERS. 

Fig.  318. 


427 


Dislocation  of  the  carpus  forward.    (Hamilton.) 
Fig.  319. 


Dislocation  of  the  carpus  backward.    (Hamilton.) 

Dislocations  of  the  Bones  of  the  Carpus.— Displace- 
ment of  the  individual  bones  of  the  carpus  occasionally 
takes  place,  the  os  magnum,  the  semilunar,  and  pisiform 
being  the  bones  most  usually  displaced,  although  other 
bones  of  the  carpus  are  sometimes  dislocated.  Reduction 
is  effected  by  means  of  extension  and  pressure,  and  the 
part  should  afterward  be  dressed  with  a  palmar  splint  and 
compresses. 

Dislocations  of  the  Metacarpal  Bones. — The  meta- 
carpal bones  may  be  dislocated  from  the  carpus  ;  the  bones 
most  commonly  displaced  are  those  of  the  thumb  and  of 
the  index  and  middle  fingers  ;  the  latter  are  usually  dis- 
placed backward,  while  the  metacarpal  bone  of  the  thumb 
may  go  either  backward  or  forward. 

Reduction  is  effected  by  extension  and  pressure.  The 
dressing  after  reduction  consists  in  the  application  of  a 
palmar  splint  to  the  hand  and  forearm  and  a  compress 
over  the  displaced  bone.  The  dressings  should  be  retained 
for  two  weeks. 

Dislocations  of  the  Fingers. — Dislocations  of  the 
phalanges  of  the  fingers  usually  take  place  at  the  meta- 


428 


DISLOCATIONS. 


carpo-phalangeal  junction,  but  sometimes  occur  at  the  inter- 
phalangeal  joints.  The  reduction  is  usually  easily  effected 
by  extension  (Fig.  320),  or  by  pushing  the  phalanx  back 
until  it  stands  perpendicularly  upon  the  metacarpal  bone, 
when  by  strong  pressure  upon  its  base,  from  behind, 
forward,  it  is  readily  carried  by  flexion  into  its  natural 
position. 

Where  difficulty  is  experienced  in  making  extension  in 
the  reduction  of  these  dislocations,  the  ingenious  apparatus 

Fig.  320. 


Backward  dislocation  of  phalanx.    Reduction  by  extension.     (Hamilton.) 

of  the  late  Dr.  Levis  (Fig.  321),  or  the  "Indian  puzzle" 
apparatus  (Fig.  322),  may  be  employed  with  success. 

In  dislocations  of  the  proximal  phalanx  of  the  thumb 
backward  (Fig.  323)  great  difficulty  in  reduction  is  often 
experienced  from  the  head  of  the  metacarpal  bone  slipping 
between  the  heads  of  the  short  flexor  of  the  thumb     The 

Fig.  321. 


Levis's  apparatus  for  dislocation  of  the  phalanges  applied. 

interposition  of  the  external  sesamoid  bone  is  considered 
by  some  surgeons  to  be  the  cause  of  difficulty  in  the 
reduction  of  this  displacement. 

In  this  dislocation  reduction  is  effected  by  firmly  press- 
ing the  metacarpal  bone  of  the  thumb  strongly  toward  the 


DISLOCATIONS  OF  THE  FINGERS. 


129 


palm  of  the  hand,  to  relax  the  two  [tortious  of  the  short 

flexor  muscle.  The  thumb  is  next  extended  upon  the 
wrist  until  its  tip  points  to  the  elbow.  An  assistant  next 
places  his  finger  behind  the  proximal  phalanx  to  prevent 
its  slipping  backward,  and  by  bringing  the  thumb  down  to 


Fig.  3-22. 


Extension  by  Indian  puzzle.     (Bryant.j 

the  flexed  position  the  bone  slips  into  place.  It  sometimes 
happens  that  all  efforts  at  reduction  fail,  and  in  such  cases 
it  may  be  necessary  to  divide  one  head  of  the  short  flexor 
muscle  subcutaneously  or  through  an  open  wound  before 
the  displacement  can  be  relieved. 

Fig.  323. 


Dislocation  of  proximal  phalanx  of  thumb  backward.    'Farabeuf.i 

The  dressing  of  dislocation-  of  the  phalanges  after  re- 
duction consists  in  the  application  of  splints  of  wood,  or 
moulded  splints  of  binders'  board,  or  gutta-percha,  to  fix 
the  joint,  which  should  be  retained  for  ten  days  or  two 
weeks. 


430 


DISLOCATIONS. 


Dislocations  of  the  Hip. — The  head  of  the  femur  is 
most  frequently  dislocated  backward,  downward,  or  up- 
ward, although  it  may  assume  other  positions  in  excep- 
tional cases. 

Posterior  or  Backward  Dislocations  of  the  Head  of  the 
Femur. — These   are  either  backward  and    upward,  when 


Fig.  324. 


Fk 


Backward  and  upward  dislocation 
of  femur.    (Cooper.) 


Backward  dislocation  of  femur. 
(Cooper.) 


they  are  described  as  iliac  or  dorsal,  the  bone  resting  upon 
the  dorsum  of  the  ilium  (Fig.  324);  or  the  dislocation  may 
be  backward,  the  head  of  the  bone  resting  upon  the  ischi- 
atic  notch ;  these  are  known  as  ischiatic  dislocations,  or  dis- 
locations of  the  femur,  dorsal  below  the  tendon  (of  the 
obturator  internus),  according  to  Bigelow  (Fig.  325). 


DISLOCATIONS  OF  THE  HIP.  431 

The  reduction  of  the  posterior  dislocations  of  the  femur 
can  generally  be  effected  by  manipulation.  The  patient 
being  anaesthetized  and  placed  upon  his  back,  the  surgeon 
grasps  the  leg  at  the  ankle  and  knee,  flexes  the  leg  upon 
the  thigh,  and  the  thigh  upon  the  pelvis  in  the  position  of 
adduction ;  he  then  abducts  the  limb  and  rotates  it  out- 
ward, bringing  it  in  a  broad  sweep  across  the  abdomen, 
and  by  bringing  it  down  to  its  natural  position  the  head 
of  the  bone  will  slip  into  the  acetabulum  (Fig.  326). 

Kocher,  in  posterior  dislocations,  recommends  the  fol- 
lowing manipulations:  1.  The  surgeon  grasps  the  ankle 

Fig.  326. 


Reduction  of  backward  dislocation  of  the  femur.    (Bigelow.) 

of  the  injured  limb  with  one  hand  and  the  front  of  the 
knee  with  the  other,  and  rotates  the  thigh  inward,  to  relax 
the  capsule  and  lift  the  head  of  the  bone  from  the  posterior 
surface  of  the  pelvis.  2.  The  thigh  is  next  flexed  to  90 
degrees,  preserving  the  existing  adduction  and  inward 
rotation.  3.  Traction  is  then  made  in  the  line  of  the 
femur,  to  make  the  capsule  tense.  4.  External  rotation 
is  then  practised,  which  makes  the  posterior  part  of  the 
capsule  and  Y-ligament  tense,  and  returns  the  head  of  the 
bone  to  the  acetabulum. 

Allis,  in  the   reduction   of  dorsal   dislocations,  recom- 
mends that,  while  the  patient  is  supine,  the  surgeon  kneel 


432 


DISLOCATIONS. 


beside  him,  and  in  the  case  of  the  right  arm  grasp  the 
ankle  with  the  right  hand  and  place  the  bent  elbow  of  the 
left  arm  beneath  the  knee.  He  then  turns  the  bent  leg 
outward  by  means  of  the  ankle  and  lifts  upward,  and 
next  turns  the  leg  inward  and  brings  the  femur  down  in 
extension. 

Downward  and  Forward  Dislocation  of  the  Head  of  the 
Femur. — In  this  variety  of  dislocation  the  head  of  the  bone 

Fig.  327. 


Downward  and  forward  dislocation  of  femur.     (Cooper.) 


rests  upon  the  thyroid  foramen  ;  this  form  of  displacement 
is  sometimes  spoken  of  as  a  thyroid  dislocation  (Fig.  327). 
The  reduction  of  downward  and  forward  dislocations  of 
the  head  of  the  femur  is  effected  by  flexing  the  leg  and 
thigh  and  bringing  the  limb  into  a  position  of  abduction; 


DISLOCATIONS  OF  THE  HIP.  433 

it  is  then  adducted  and  rotated  inward  in  a  broad  sweep 
across  the  abdomen  and  brought  down  to  its  natural  posi- 
tion, when  the  head  of  the  bone  slips  into  the  acetabulum 
(Fig  328). 

In  making  these  manipulations  the  head  of  the  bone 
sometimes  slips  back  upon  the  dorsum  of  the  ilium,  con- 
verting the  downward  dislocation  into  a  posterior  one ;  if 
this  accident  occurs,  the  displacement  should  be  reduced 
by  making  the  manipulations  appropriate  for  the  reduction 
of  the  latter  dislocation. 

Kocher,  in  the  reduction  of  these  dislocations,  recom- 
mends the  following  manipulations:    1.  The  leg  should  be 

Fig.  328. 


Reduction  of  downward  and  forward  dislocation  of  femur.    (Bigelow.) 

flexed  upon  the  thigh  and  the  thigh  carried  up  to  a  right 
angle  with  the  pelvis,  maintaining  abduction  and  external 
rotation,  to  relax  the  Y-ligament.  2.  Traction  should 
next  be  made  in  the  line  of  the  shaft  of  the  femur,  to 
render  the  posterior  part  of  the  capsule  tense.  3.  Out- 
ward rotation  is  then  made,  which,  twisting  the  tense  pos- 
terior portion  of  the  capsule  and  the  outer  branch  of  the 
Y-ligament,  brings  the  head  of  the  bone  upward  and 
backward  into  the  acetabulum. 

Forward  and  Upward  Dislocation  of  the   Head  of  the 

28 


434 


DISLOCATIONS. 


Femur. — In  this  variety  of  dislocation,  which  is  very  rare, 
the  head  of  the  bone  rests  upon  the  pubis  ;  this  form  of 
displacement  is  also  spoken  of  as  a  pubic  dislocation 
(Fig.  329). 

The  reduction  of  forward  and  upward  dislocations  of 
the  head  of  the  femur  is  effected  by  much  the  same  manip- 
ulation as  is  employed  in  the  reduction  of  downward  and 

Fig.  329. 


Forward  and  upward  dislocation  of  the  femur.    (Cooper.) 

forward  dislocations,  except  that  in  the  pubic  dislocation 
the  flexed  limb  should  be  carried  across  the  sound  thigh 
at  a  higher  point.  The  thigh  being  flexed,  the  head  of  the 
bone  is  drawn  down  from  the  pubis ;  it  is  then  semi- 
abducted  and  rotated   inward  to  disengage  the  bone  com- 


DISLOCATIONS  OF  THE  PATELLA.  435 

pletely.  While  rotating  inward  and  drawing  on  the  thigh 
the  knee  should  be  carried  inward  and  downward  to  its 
place  by  the  side  of  its  fellow,  and  the  head  of  the  bone 
will  usually  slip  into  the  acetabulum. 

Kocher,  in  the  reduction  of  forward  and  upward  disloca- 
tions of  the  femur,  recommends:  1.  Traction  should  first 
be  made  in  the  axis  of  the  limb,  to  bring  the  head  of  the 
bone  over  the  brim  of  the  pelvis.  2.  Pressure  should  next 
be  made  with  the  hand  upon  the  head  of  the  femur,  to 
prevent  its  passing  upward  during  flexion  of  the  thigh. 
3.  The  thigh  should  next  be  flexed  to  less  than  a  right 
angle,  to  relax  the  Y-ligament.  4.  Inward  rotation  is 
next  made,  which  directs  the  head  of  the  bone  into  the 
acetabulum. 

Anomalous  Dislocations  of  the  Head  of  the  Femur. — These 
occasionally  occur ;  the  head  of  the  bone  may  pass  directly 
upward  or  downward  between  the  sciatic  notch  and  thyroid 
foramen,  or  downward  and  backward  on  the  body  of  the 
ischium,  or  downward  and  backward  into  the  lesser  sciatic 
notch,  or  downward,  inward,  and  forward  into  the  peri- 
neum. These  anomalous  displacements  usually  occur  where 
there  has  been  extensive  laceration  of  the  capsular  ligament 
and  Y-ligament. 

The  dressing  of  cases  after  reduction  of  dislocations  of 
the  head  of  the  femur  consists  in  keeping  the  patient  at 
rest  in  bed  upon  his  back;  the  limb  should  be  kept  at 
rest  by  sand  bags  applied  to  either  side  of  the  limb,  or  the 
knees  should  be  tied  together.  The  patient  should  be 
kept  at  rest  for  two  or  three  weeks,  and  at  the  end  of 
this  time  may  be  allowed  to  get  out  of  bed  and  go  about 
on  crutches. 

Dislocations  of  the  Patella.— The  patella  may  be  dis- 
located outward,  inward,  or  upward,  or  it  may  be  rotated 
upon  its  own  axis.  The  outward  dislocation  is  the  dis- 
placement most  usually  seen  (Fig.  330). 

Upward  dislocation  of  the  patella  can  only  result  from 
laceration  of  the  ligamentum  patella?,  and  the  treatment  in 
such  cases  is  similar  to  that  for  fracture  of  the  patella. 
The  reduction  of  dislocations  of  the  patella  is  effected 


436 


DISLOCATIONS. 


by  extending  the  leg  upon  the  thigh  and  flexing  the  thigh 
upon  the  pelvis,  to  relax  the  quadriceps  femoris  muscle, 
when  the  patella  can  usually  be  forced  back  into  place  by 
manipulation  with  the  fingers;  in  some  cases  alternate 
flexion  and  extension  of  the  leg  will  accomplish  the  same 
result. 

The  dressing  after  reduction  of  the  displacement  consists 
in  the  application  of  a  posterior  straight  splint  or  a  moulded 

Fig.  330. 


Outward  dislocation  of  the  patella.     (Duplay.) 

binders'  board  or  felt  splint  to  keep  the  joint  at  rest ;  the 
splint  should  be  worn  for  a  week  or  ten  days. 

Dislocations  of  the  Knee. — The  head  of  the  tibia  may 
be  dislocated  forward,  backward,  or  laterally ;  the  latter 
dislocations  are  always  incomplete,  forward  dislocation 
being  the  variety  of  displacement  most  commonly  met  with 
(Fig.  331). 

The  reduction  of  dislocations  of  the  knee  is  effected  by 


DISLOCATION  OF  SEMILUNAR  CARTILAGES.     437 

extension  and  counter-extension  with  forced  flexion  of  the 
knee  with  pressure,  aided  by  rocking  movements.  The 
treatment  of  cases  of  dislocation  of  the  knee  after  reduc- 
tion consists  in  fixing  the  knee-joint  by  the  application  of 
a  straight  posterior  splint  or  a  moulded  splint  of  binders' 
board.  As  there  is  usually  marked  swelling  following 
these  injuries  from  violence  to  the  joint-structures,  the 
application  of  evaporating  lotions  for  a  few  days  will  be 
found  useful.  As  soon  as  the  swelling  has  subsided,  the 
joint  should  be  put  up  in  a  plaster-of- Paris  dressing,  and 
this  should  be  retained  for  four  weeks. 


External  condyle  of  femur 
Forward  dislocation  of  the  knee.    (Bryant.) 

Dislocation  of  the  Semilunar  Cartilages. — The  dis- 
placement here  consists  in  the  slipping  forward  or  back- 
ward and  wedging  of  the  semilunar  cartilages  between  the 
femoral  condyles  and  the  tibia. 

Reduction  of  the  displaced  cartilages  can  usually  be 
effected  by  hyperflexion  of  the  knee,  followed  by  sudden 
full  extension,  or  by  alternately  flexing  and  extending  the 
joint.  Excision  of  the  displaced  cartilages  is  sometimes 
required  in  cases  in  which  they  cannot  be  reduced  by 
manipulation. 

The  dressing  of  these  cases  after  reduction  of  the  dis- 
placed cartilages  consists  in  the  application  of  a  posterior 
straight  splint  or  a  plaster-of- Paris  dressing  to  fix  the  knee- 
joint;  the  splint  should  be  worn  for  three  or  four  weeks, 
and  if  there  is  a  tendency  to  redisplacement,  the  patient 
should  wear  a  brace,  or  a  knee-cap  of  leather  or  muslin, 


438 


DISLOCATIONS. 


to  partially  fix  the  joint,  with  compresses  so  arranged  as 
to  make  pressure  upon  the  edge  of  the  joint. 

Dislocations  of  the  Fibula.— Dislocations  of  the  fibula 
may  occur  at  either  of  its  extremities,  and  the  direction  of 
the  displacement  may  be  forward,  backward,  or  oidward  ; 
dislocation  of  the  head  or  upper  extremity  of  the  fibula 
being  the  most  common,  although  all  are  rare  forms  of 
displacement. 

The  reduction  of  dislocations  of  the  head  of  the  fibula 
is  effected  by  flexing  the  leg  upon  the  thigh  and  making 
direct  pressure  and  extension.  Dislocations  of  the  lower 
extremity  of  the  fibula  are  reduced  by  manipulation  and 
pressure.  The  dressing  of  cases  after  reduction  of  dislo- 
cations of  the  fibula  consists  in  the  application  of  a  com- 
press and  moulded  binders'  board  splint ;  the  dressing 
should  be  retained  for  three  or  four  weeks. 

Dislocations  of  the  Ankle. — Dislocations  of  the  foot 
upon  the  bones  of  the  leg  result  from  separation   of  the 


Fig.  332. 


Fig.  333. 


Dislocation  of  foot  backward. 
(Bryant.) 


Dislocation  of  foot  inward. 
(Bryant.) 


articular  surface  of  the  astragalus  from  that  of  the  tibia 
and  fibula ;  the  displacement  may  be  forward,  backward 
(Fig.  332),  or  lateral  (Fig.  333),  the  latter  variety  being 
often  associated  with  fractures  of  the  malleoli. 


DISLOCATIONS  OF  THE   TARSAL  BOXES.         439 

The  reduction  of  dislocations  of  the  ankle  is  effected  by 
traction,  combined  with  flexion  and  rotation  of  the  ankle- 
joint,  the  leg  being  first  flexed  upon  the  thigh  to  relax  the 
tendo-Achillis,  and  in  some  cases  the  subcutaneous  division 
of  this  tendon  is  required  before  the  reduction  can  be  satis- 
factorily accomplished. 

The  dressing  of  dislocations  of  the  ankle  after  reduction 
consists  in  the  application  of  a  fracture-box  or  of  paste- 
board splints,  to  fix  the  ankle,  care  being  taken  to  see  that 
the  foot  is  fixed  at  a  right  angle  to  the  leg,  and  in  the 
application  of  evaporating  lotions  for  a  few  days ;  after 
the  swelling  has  subsided  a  plaster-of- Paris  dressing  should 
be  applied  and  retained  for  three  or  four  weeks. 

Dislocations  of  the  Tarsal  Bones. — The  astragalus 
may  be  dislocated  from  the  bones  of  the  leg  and  from  the 
other  tarsal  bones,  being  thrust  forward,  backward,  out- 
ward (Fig.  334),  or  inward.  The  reduction  of  dislocations 
of  the  astragalus  outward  is  effected  by  first  flexing  the 
leg  upon  the  thigh  and  making  extension  from  the  foot 
and  rotating  it  at  the  same  time,  direct  pressure  being 
made  upon  the  displaced  bone  ;  in  some  cases  subcutane- 
ous section  of  the  tendo-Achillis  has  assisted  materially  in 
the  reduction  of  the  displaced  bone.  Backward  disloca- 
tion of  the  astragalus  is  usually  irreducible  ;  the  patient, 
however,  in  many  cases  recovers  with  a  useful  foot.  In 
cases  of  irreducible  dislocations  of  the  astragalus  excision 
of  the  astragalus  may  ultimately  be  required. 

After  the  reduction  of  dislocations  of  the  astragalus,  the 
foot  and  leg  should  be  put  at  rest  in  a  fracture-box,  or  by 
means  of  moulded  splints  of  pasteboard  or  felt ;  evaporat- 
ing lotions  should  also  be  employed  over  the  region  of  the 
injury  for  a  few  days,  and  when  the  swelling  has  subsided 
a  plaster-of-Paris  dressing  should  be  applied  and  retained 
for  three  or  four  weeks. 

Dislocations  of  the  calcaneum  and  scaphoid  upon  the 
astragalus,  or  of  the  calcaneum  upon  the  astragalus  and 
cuboid,  or  upon  the  astragalus  alone ;  of  the  scaphoid  and 
cuboid  upon  the  ccdcis  and  astragalus;  or  of  the  cuboid, 
scaphoid,  or  cuneiform  bones,  are  occasionally  met  with. 


440 


DISLOCATIONS. 


Their  reduction  is  effected  by  traction  and  direct  press- 
ure, and  after  this  has  been  accomplished  the  parts  should 
be  put  at  rest  by  the  application  of  a  splint  and  compresses. 


Fig.  334. 


Dislocation  of  astragalus  outward.    (Hamilton.) 

Dislocations  of  the  Metatarsal  Bones  and  Phalanges 
of  the  Toes. — These  dislocations  usually  result  from 
crushing  forces  which  destroy  the  vitality  of  the  soft  parts 
so  completely  that  amputation  is  required.  Their  reduc- 
tion in  cases  of  simple  or  uncomplicated  dislocations  is 
effected  by  traction,  manipulation,  and  pressure.  After 
reduction  of  the  displacement  the  parts  should  be  kept  in 
position  by  the  application  of  splints,  compresses,  and 
bandages. 

Old  Dislocations. 

The  reduction  of  old  dislocations  is  attended  with  more 
difficulty  and  danger  than  that  of  recent  dislocations,  due 


OLD  DISLOCATIONS 


441 


to  the  permanent  contraction  and  structural  changes  which 
occur  in  the  muscles  and  to  the  adhesions  which  form 
between  the  displaced  bone  and  the  parts  with  which  it  is 
in  contact.  The  reduction  of  old  dislocations  may  usually 
be  accomplished  by  the  manipulations  appropriate  for  re- 
cent dislocations  of  the  same  variety  ;  but  occasionally  the 

Fig.  335. 


Reduction  of  old  dislocation  of  hip  by  vertical  extension.    (Bigelow.) 

use  of  more  forcible  extension  is  required,  which  is  made 
by  bands  and  pulleys  or  by  vertical  extension  (Fig.  335). 
The  first  step  in  the"  reduction  of  old  dislocations  consists 
in  thoroughly  breaking  up  the  adhesions  which  have 
been  formed  between  the  displaced  bone  and  the  surround- 
ing tissues :  this  has,  in  some  cases,  resulted  in  the  lacera- 


442  DISLOCATIONS. 

tion  of  muscles,  nerves,  and  bloodvessels,  and  in  fracture 
of  the  displaced  hones  or  neighboring  bones,  so  that 
the  manipulations  should  be  made  with  the  least  force 
that  will  accomplish  the  object  desired.  After  the  reduc- 
tion of  old  dislocations  difficulty  is  sometimes  experienced 
in  maintaining  the  bone  in  its  proper  place,  due  to  the 
changes  which   have  occurred   in  the  articular  surfaces. 

If  the  dislocation  under  this  method  of  treatment  is 
found  to  be  irreducible,  and  the  patient  suffers  from  great 
pain  and  disability,  open  operation  is  advisable.  This 
consists  in  exposing  the  displaced  bone  and  dividing  the 
soft  tissues  which  interfere  with  reduction  or  in  making 
a  complete  or  incomplete  excision  of  the  joint. 

Compound  Dislocations. 

These  are  always  grave  injuries,  and  amputation  or 
excision  may  be  required.  At  the  present  time,  under  the 
modern  methods  of  wound  treatment,  operative  measures 
are  not  often  required.  The  reduction  is  effected  in  the 
same  manner  as  in  simple  dislocations  of  corresponding 
parts,  the  greatest  care  being  taken  to  render  the  wound 
aseptic,  and  to  keep  it  in  this  condition  by  the  application 
of  a  full  antiseptic  dressing.  After  reducing  the  disloca- 
tion and  dressing  the  wound  some  form  of  fixation  splint 
should  be  applied,  to  fix  the  joint  for  a  short  time. 

Complicated  Dislocations. 

In  dislocations  complicated  by  fracture  near  the  seat  of 
displacement,  the  displaced  bone  should,  if  possible,  be 
first  reduced,  and  this  in  many  cases  is  a  matter  of  great 
difficulty,  as  the  fracture  prevents  the  surgeon  from  using 
leverage  otherwise  present,  in  the  reduction,  and  he  has 
often  to  depend  entirely  upon  pressure  and  manipulation 
to  overcome  the  displacement.  After  reduction  of  the 
dislocation  the  fracture  should  be  reduced  and  dressed. 

Dislocation  complicated  by  rupture  of  the  main  artery 
of  the  limb  may  require,  after  reduction  of  the  displace- 


PATHOLOGICAL  DISLOCATIONS.  443 

ment,  exposure  and  ligation  of  the  vessel  or  amputation 
of  the  limb.  Rupture  of  an  important  nerve-trunk  com- 
plicating a  dislocation  may  call  for  subsequent  exposure 
and  suturing:  of  the  divided  nerve. 

Habitual,  Pathological,  and  Congenital  Dislocations. 

In  the  treatment  of  these  varieties  of  dislocations  after 
the  reduction  of  the  displacement  by  manipulation  and 
pressure,  much  difficulty  is  often  experienced  in  maintain- 
ing the  reduction.  To  effect  the  latter  object,  the  use  of 
splints  and  bandages  is  employed,  and  also  the  use  of  many 
ingenious  forms  of  apparatus  adapted  to  particular  dislo- 
cations. Operative  treatment  such  as  excision  of  a  por- 
tion of  the  capsule  of  the  joint  or  ligaments,  or  operation 
upon  the  bone  to  increase  the  capacity  of  the  joint,  may  be 
practised. 

Tenotomy  or  myotomy  is  often  required  to  prevent  re- 
currence of  the  deformity,  and  continuous  extension  is 
also  of  much  value  in  the  treatment  of  these  displace- 
ments. 


PAET    V. 

OPERATIONS. 


In  view  of  the  fact  that  at  the  present  time  in  medi- 
cal schools  much  attention  is  paid  to  practical  surgery 
— that  is,  operative  procedures  upon  the  cadaver — it  has 
been  thought  advisable  to  introduce  a  very  brief  descrip- 
tion of  a  number  of  operations  which  may  with  advantage 
be  performed  upon  the  cadaver.  Too  much  value  cannot 
be  attached  to  the  importance  of  the  student  rendering 
himself  familiar  with  the  use  of  instruments  and  their 
manipulation  in  the  various  operative  procedures,  and  also 
familiarizing  himself  with  the  appearance  of  the  anatomi- 
cal parts  exposed  in  operations.  The  introduction  of 
sutures,  the  application  of  ligatures,  the  closing  of  wounds, 
the  cutting  and  fitting  of  flaps  in  plastic  operations,  are 
procedures  the  practical  value  of  which  to  the  student 
cannot  be  overestimated. 


LIGATION  OF  ARTERIES. 

In  the  application  of  a  ligature  to  an  artery  in  its  con- 
tinuity the  surgeon  should  make  his  incision  in  the  line 
which  corresponds  to  the  general  course  of  the  vessel,  and 
he  should  be  thoroughly  familiar  with  the  anatomy  and 
with  the  surgical  landmarks  of  the  part.  A  portion  of 
the  artery,  when  possible,  should  be  selected  for  the  appli- 
cation of  the  ligature  half  an  inch  or  an  inch  from  any 
large  collateral  branch.     The  position  of  the  incision  being 

445 


446  OPERA  TIONS. 

selected,  the  surgeon  steadies  the  skin  with  two  fingers  and 
makes  an  incision  of  the  required  length  through  it  with 
a  scalpel ;  the  superficial  fascia  is  next  picked  up  on  a 
director,  any  large  superficial  veins  which  come  into  view 
being  displaced,  and  divided  to  an  equal  length  with  the 
incision  in  the  skin  ;  the  deep  fascia  being  exposed,  it 
should  be  nicked  and  divided  upon  a  director ;  the  inter- 
muscular space,  or  the  edge  of  the  muscle  or  muscles  which 
are  the  guide  to  the  vessel,  should  next  be  sought  for,  and 
small  arteries  coming  from  the  main  vessel  through  these 
spaces  will  often  serve  as  valuable  guides  to  the  position 
of  the  artery.  The  surgeon  next  separates  the  tissues  with 
the  director  or  handle  of  the  knife  until  the  sheath  of  the 
vessel  is  exposed ;  this  is  recognized  by  its  communicated 
pulsation  and  by  the  absence  of  the  smooth,  shining 
surface  and  pinkish-white  color  which  the  surface  of  the 
artery  presents.  The  sheath  of  the  artery  should  be  picked 
up  with  forceps  and  nicked  with  the  point  of  the  knife 
applied  flatwise  (Fig.  337,  A) ;  the  incision  into  the  sheath 
should  be  very  limited,  only  sufficiently  large  to  allow 
the  aneurism  needle  to  pass  through  it  around  the  vessel ; 
extensive  dissections  or  separations  of  the  sheath  from  the 
artery  should  be  avoided,  as  the  nutrition  of  the  artery  at 
the  point  of  ligature  may  thus  be  impaired,  and  sloughing 
and  secondary  hemorrhage  may  result.  A  distinct  sheath 
is  found  only  about  the  main  arterial  trunks,  which  is 
replaced  in  the  smaller  arteries  by  a  layer  of  loose  cellular 
tissue.  The  wall  of  the  artery  being  exposed,  an  aneurism 
needle  (Fig.  336)  is  passed  around  the  vessel,  threaded 
with  a  catgut  ligature,  and  withdrawn  (Fig.  337,  B) :  the 
needle  may  be  threaded  before  being  passed,  in  which 
case  the  ligature  is  grasped  with  forceps  and  drawn 
through  while  the  needle  is  withdrawn.  The  best  ma- 
terial for  ligatures  is  silk  or  carefully  prepared  chromi- 
cized  catgut.  The  needle  should  be  passed  away  from 
important  structures,  such  as  accompanying  veins  and 
nerves. 

Before  the  ligature  is  tied  the  surgeon    should  satisfy 
himself  that  the  ligature  when  tied  will  control  the  circu- 


LIGATION  OF  THE  INNOMINATE  ARTERY.       447 

lation  in  the  artery  below  its  point  of  application,  by 
placing  the  tip  of  his  finger  upon  the  vessel  and  drawing 
upon  the  ends  of  the  ligature,  so  as  to  occlude  the  vessel 
at  the  point  of  application.  Being  satisfied  as  to  this 
point,  the  ligature  is  tied  with  a  reef-knot,  or  a  surgeon's 
knot  and  reef-knot  combined,  and  the  ends  of  the  ligature 
are  cut  short  in  the  wound  (Fig.  337,  C). 


Fig.  336. 


Fro.  337. 


Aneurism  needle.  A,  opening  sheath ;  B,  passing  ligature  around  the 

vessel ;  C,  tying  the  artery. 

Some  authorities  recommend  the  application  of  two  liga- 
tures a  short  distance  apart  in  the  ligation  of  vessels  in 
their  continuity,  and  a  division  of  the  vessel  between  them, 
so  that  both  ends  may  retract  into  the  cellular  sheath. 


Ligation  of  Special  Arteries. 

Ligation  of  the  Innominate  Artery.— The  innominate 
arterv  lies  immediately  behind  the  sterno-elavicular  artic- 
ulation, and  is  in  relation  in   front  with  the  innominate 


448  OPERATIONS. 

veins  and  pneumogastric  nerve,  on  the  inner  side  with  the 
trachea,  on  the  outer  side  and  behind  with  the  pleura. 

The  incision  is  a  V-shaped  incision,  each  branch  of 
which  is  two  and  a  half  or  three  inches  in  length,  one  of 
which  lies  over  the  anterior  edge  of  the  sternocleido- 
mastoid muscle  and  the  other  parallel  to  and  a  little  above 
the  clavicle  (Fig.  338,  A).  The  incisions  are  carried  down 
to  the  superficial  fascia  and  a  flap  is  dissected  up.  If  the 
anterior  jugular-  vein  is  met  with,  it  should  be  displaced. 


V  """""" 

"A 
\ 

1 

Se 

\ 

B 

A 

/ 


Lines  of  incision  for—  A,  innominate  artery  ;  B,  right  subclavian  artery ; 
C,  left  subclavian  artery ;  D,  vertebral  or  inferior  thyroid  arterv ;  E,  axillary 
artery  below  clavicle.    (Stimson.) 

The  sternal  and  clavicular  attachments  of  the  sterno- 
cleido-mastoid  are  next  divided  upon  a  director  half  an 
inch  above  the  bone.  The  sternothyroid  and  sterno- 
hyoid muscles  and  the  middle  cervical  fascia  are  then  ex- 
posed, covered  by  the  thyroid  veins.  The  outer  fibres  of 
the  sterno-hyoid  and  sterno-thyroid ,  muscles  are  next 
divided,  the  thyroid  vein  being  held  aside,  when  upon 
tearing  through  the  fascia  with  a  director  the  common 
carotid  artery  is  exposed  and  traced  down  to  the  innomi- 
nate artery ;  the  innominate  veins  are  pressed  against  the 
sternum  with  the  finger,  and  the  artery  is  separated  from 


LIGATION  OF  THE  SUBCLAVIAN  ARTERY.      449 

its  sheath  about  half  an  inch  below  its  bifurcation,  and  the 
aneurism  needle  is  passed  around  the  vessel  from  the  outer 
side,  so  as  to  avoid  the  vein,   pneumogastric  nerve,  and 

pleura.  . 

Ligation  of  the  Subclavian  Artery.— This  artery  may 
be  tied  at  three  points ;  in  its  first  portion,  between  the 
trachea  and  scaleni  muscles ;  in  its  second  portion,  behind 
the  scaleni  muscles ;  and  in  its  third  portion,  external  to 
the  scaleni  muscles. 

The  left  subclavian  artery  in  its  first  portion  is  larger 
and  more  vertical  in  its  direction  than  the  right  subclavian, 
and  is  situated  more  posteriorly.  From  the  difficulty^ 
exposing  this  portion,  and  from  the  possibility  of  injuring 
the  thoracic  duct,  the  ligation  of  this  artery  in  its  first 
portion  has  been  seldom  attempted. 

The  incision  for  the  first  portion  of  the  subclavian  artery 
is  the  same  as  that  for  the  innominate  (Fig.  338,  A),  and 
the  ligature  is  passed  from  the  outer  side,  the  pneumogas- 
tric and  phrenic  nerves  being  pressed  inward  toward  the 
carotid  artery. 

The  right  and  left  subclavian  arteries  are  also  seldom 
tied  in  their  second  portions— that  is,  behind  the  scaleni 
muscles— but  are  frequently  tied  in  their  third  portions— 
that  is,  external  to  the  scaleni  muscles. 

The  incision  for  the  second  portion  of  the  subclavian 
artery  begins  an  inch  external  to  the  sterno-clavicular 
articulation,  half  an  inch  above  and  parallel  to  the  clav- 
icle, and  is  three  or  four  inches  in  length  (Fig.  338,  B  or 
C).  The  steps  of  the  operation  are  the  same  as  for  liga- 
tion of  the  third  portion,  and  when  the  scalenus  anticus 
muscle  has  been  exposed,  it  is  divided  upon  a  director  ;  the 
phrenic  nerve,  which  lies  upon  its  anterior  aspect,  is  to  be 
avoided. 

The  incision  for  the  third  portion  of  the  subclavian  artery 
is  the  same  as  for  the  second  portion  (Fig.  338,  B  or  C). 
The  skin  and  platysma  being  divided,  the  external  jugular 
vein  is  exposed  and  drawn  to  one  side  or  divided  between 
two  ligatures ;  the  superficial  fascia  is  next  divided  upon  a 
director ;  the  posterior  belly  of  the  omo-hyoid  muscle  is 

29 


450 


OPERA  TJONS. 


next  found  and  drawn  upward  and  outward  ;  the  outer 
border  of  the  scalenus  anticus  is  next  felt  for  and  followed 
down  to  the  tubercle  of  the  first  rib — the  artery  lies  against 
this,  between  it  and  the  lowest  bundle  of  the  brachial 
plexus.  The  artery  is  next  denuded  with  the  director, 
and  the  needle  is  passed  from  below,  care  being  taken  not 

Fig.  339. 


Ligation  of  subclavian  and  lingnal  arteries.     (Bryant.) 

to  include  the  lowest  bundle  of  the  brachial  plexus  in  the 
ligature  (Fig.  339). 

Ligation  of  the  Vertebral  Artery. — The  incision  for 
the  ligation  of  the  vertebral  artery  is  three  or  three  and  a 
half  inches  in  length,  parallel  with  the  anterior  edge  of 
the  sterno-cleido-mastoid   muscle,  ending  an   inch   above 


LIGATION  OF  THE  COMMON  CAROTID  ARTERY.   451 

the  clavicle  (Fig.  338,  /)).  The  anterior  edge  of  the 
sterno-cleido-mastoid  being  exposed,  the  middle  cervical 
fascia  is  divided  and  the  carotid  artery  and  jugular  vein 
are  exposed  and  drawn  inward.  The  gap  between  the 
longus  colli  muscle  and  the  scalenus  anticus  muscle  is 
next  felt  for  about  an  inch  below  the  carotid  tubercle  ;  the 
fascia  covering  it  is  next  torn  through  and  the  muscles  are 
separated  and  the  vertebral  vein  comes  into  view.  When 
this  vein  is  held  aside  the  vertebral  artery  is  exposed,  and 
the  ligature  is  then  passed  around  it. 

Ligation  of  the  Inferior  Thyroid  Artery.— The  in- 
cision for  the  inferior  thyroid  artery  is  the  same  as  that  for 
the  vertebral  artery  (Fig.  338,  D).  The  anterior  edge  of 
the  sterno-cleido-mastoid  muscle  being  exposed,  it  is  drawn 
outward,  the  middle  cervical  fascia  is  next  divided,  and  the 
carotid  artery  and  internal  jugular  vein  are  drawn  outward 
with  a  retractor.  The  head  being  flexed  slightly,  the  sur- 
geon feels  for  the  carotid  tubercle,  and  then  separates  the 
cellular  tissue  with  a  director,  and  the  artery  should  be 
found  below  the  carotid  tubercle.  The  needle  should  be 
passed  between  the  artery  and  vein. 

Ligation  of  the  Internal  Mammary  Artery. — The 
incision,  a  vertical  one,  two  and  a  half  inches  in  length, 
commences  at  the  lower  border  of  the  clavicle,  parallel 
with  and  three  lines  external  to  the  margin  of  the  ster- 
num. Divide  the  skin  and  superficial  fascia  and  expose 
the  fibres  of  the  great  pectoral  muscle,  the  external  inter- 
costal aponeurosis,  and  the  muscular  fibres  of  the  internal 
intercostal  muscle.  Raise  the  fasciculi  of  the  latter  mus- 
cle upon  a  director  and  divide  them,  and  the  vessel  will 
be  exposed.  The  internal  mammary  artery  is  not  often 
tied  below  the  fourth  intercostal  space. 

Ligation  of  the  Common  Carotid  Artery. — The  point 
of  election  for  the  ligation  of  the  common  carotid  artery 
is  just  above  the  omo-hyoid  muscle,  about  three-quarters 
of  an  inch  below  the  bifurcation  of  the  vessel,  which  takes 
place  at  a  point  on  a  line  with  the  upper  border  of  the 
thyroid  cartilage. 

The  incision  for  the  common   cartoid   artery  is  three 


452 


OPERA  TIONS. 


Fig.  840. 


Line  of  incision  for  common  carotid  artery  at  point  of  election.    (Stimson.) 

Fig.  341. 


Relations  of  the  left  common  carotid  artery  above  the  omo-hyoid  muscle. 

(Esmarch.)  " 

inches  in  length  along  the  anterior  border  of  the  sterno- 
cleido-mastoid  muscle,  the  centre  of  which  corresponds 
with  the  crico-thyroid  space  (Fig.  340). 


LIGATION  OF  THE  EXTERNAL  CAROTID  ARTERY.  453 

Divide  the  skin,  platysma,  cellular  tissue,  and  aponeu- 
rosis, avoiding  the  superficial  veins,  and  expose  the  ante- 
rior edge  of  the  sterno-cleido-mastoid  ;  seek  for  the  inter- 
space between  this  muscle  and  the  sterno-hyoid  and 
sterno-thyroid  muscles,  draw  the  latter  muscles  inward, 
and  the  artery  will  be  exposed  with  the  jugular  vein  exter- 
nal to  it ;  the  descendens  noni  nerve  lying  upon  its  sheath 
should  be  displaced  outward.  The  sheath  is  next  picked 
up  and  opened  and  the  artery  is  separated  from  it  with 
a  director;  the  artery  lies  internally,  the  internal  jugular 
vein  externally  and  somewhat  more  superficial,  and  the 
pneumogastric  nerve  lies  between  the  two,  and  is  more 
deeply  placed.  The  sympathetic  nerve  is  posterior  to  the 
vessel  external  to  the  sheath.  The  needle  is  passed  from 
without  inward,  care  being  taken  to  avoid  injury  of  the 
vein  and  nerve  (Fig.  341). 

Ligation  of  the  External  Carotid  Artery. — The  in- 
cision for  the  ligation  of  the  external  carotid  artery  is  over 


Fig.  342. 


Lines  of  incision  for— A,  lingual  artery  ;  B,  external  and  internal  carotid  arte- 
ries ;  C,  occipital  artery  ;  D,  temporal  artery ;  E,  facial  artery.    (Stimson.) 

the  inner  edge  of  the  sterno-cleido-mastoid  muscle  from 
the  angle  of  the  jaw  to  a  point  corresponding  to  the  mid- 


454  OPERATIONS. 

die  of  the  thyroid  cartilage  (Fig.  342,  B).  The  skin,  pla- 
tysma, and  cellular  tissue  being  divided,  the  external 
jugular  vein  is  drawn  aside  when  encountered  ;  the  deep 
fascia  being  opened,  the  facial  and  lingual  veins  Avill  be 
exposed,  which  should  be  drawn  to  one  side ;  the  artery  is 
next  exposed,  covered  by  the  hypoglossal  nerve  and  the 
stylo-hyoid  and  digastric  muscles.  The  vessel  should 
next  be  isolated  from  the  internal  carotid  artery  and  inter- 
nal jugular  vein,  both  of  which  lie  along  its  outer  side. 
The  needle  should  be  passed  from  without  inward. 

Ligation  of  the  Internal  Carotid  Artery. — The  in- 
cision is  the  same  as  for  the  external  carotid  artery  (Fig. 

341,  B) ;  the  vessel  is  external  to  the  external  carotid 
artery,  and  in  passing  the  needle  the  point  should  be 
directed  away  from  the  internal  jugular  vein — that  is, 
from  without  inward. 

Ligation  of  the  Superior  Thyroid  Artery. — The  in- 
cision is  about  three  inches  in  length  along  the  anterior 
border  of  the  sterno-cleido-mastoid  muscle,  starting  a  little 
lower  down  than  that  for  the  external  carotid  artery.  The 
skin,  superficial  fascia,  platysma,  and  deep  fascia  being 
divided,  the  cellular  tissue  in  the  sulcus  between  the  upper 
portion  of  the  larynx  and  the  great  vessels  of  the  neck 
should  be  broken  up  with  the  director  and  the  vessel  ex- 
posed. The  needle  should  be  passed  around  the  vessel 
from  above  downward. 

Ligation  of  the  Lingual  Artery. — The  incision  is  a 
curved  one  two  inches  long,  its  concavity  directed  upward 
from  the  anterior  edge  of  the  sterno-cleido-mastoid  muscle, 
half  an  inch  above  the  great  horn  of  the  hyoid  bone,  to  a 
point  one  inch  within  the  median  line  of  the  neck  (Fig. 

342,  A).  Divide  the  skin  and  platysma,  displacing  the 
superficial  veins,  and  open  the  deep  fascia,  when  the  sub- 
maxillary gland  will  be  exposed  ;  this  is  displaced  upward 
with  the  handle  of  the  knife,  when  the  tendon  of  the  digas- 
tric muscle  is  attached  to  the  hyoid  bone,  and  the  hypo- 
glossal nerve  will  be  exposed  ;  next  divide  the  fibres  of  the 
hyoglossus  muscle  midway  between  the  hypoglossal  nerve 
and  the  hyoid  bone,  and  the  lingual  artery  will  be  exposed 


LIGATION  OF  THE  TEMPORAL  ARTERY.        455 

(Fig.   343).     The   needle  should    he   passed    around    the 

vessel    from    above    downward,    in    order    to    avoid    the 

nerve. 

Fig.  343. 


Relations  of  the  lingual  artery.     (Esmabch.) 

Ligation  of  the  Facial  Artery. — The  facial  artery 
passes  over  the  inferior  maxilla  just  in  front  of  the  ante- 
rior edge  of  the  masseter  muscle,  and  is  accompanied  by 
the  facial  vein,  which  lies  nearer  to  the  muscle. 

The  incision  is  either  a  horizontal  one  along  the  lower 
border  of  the  maxilla  or  a  vertical  one  an  inch  in  length 
(Fig.  342,  E).  The  skin,  subcutaneous  tissue,  and  fascia 
being  divided,  the  artery  is  exposed ;  the  needle  should 
be  passed  around  the  vessel  away  from  the  vein. 

Ligation  of  the  Occipital  Artery. — The  incision  is  two 
inches  in  length,  starting  from  a  point  half  an  inch  below 
and  in  front  of  the  apex  of  the  mastoid  process,  and  carried 
obliquely  backward,  parallel  to  the  border  of  this  process 
(Fig.  342,  C).  Divide  the  skin  and  fascia  and  expose  the 
insertion  of  the  sterno-cleido-mastoid  muscle,  which  is  also 
divided,  and  the  aponeurosis  of  the  splenitis  is  exposed  ; 
this  is  also  opened  and  the  digastric  groove  is  felt  for,  and 
when  the  belly  of  the  digastric  muscle  is  exposed  the  artery 
is  brought  into  view  by  separating  the  cellular  tissue  in  the 
anterior  angle  of  the  wound  with  a  director  (Fig.  344). 

Ligation  of  the  Temporal  Artery. — The  incision  is  a 


456 


OPERATIONS. 


transverse  one,  one  inch  in  length,  starting  from  the  tragus 
of  the  ear  forward  over  the  zygomatic  arch  (Fig.  342,  I)), 
or  a  vertical  one  of  the  same  length  a  little  in  front  of  the 
tragus  of  the  ear. 

Divide  the  skin  and  expose  the  subcutaneous  cellular 
tissue,  which  in  this  region  is  very  dense  and  fibrous. 
This  tissue  should  be  broken  up  with  a  director,  and  the 
artery  should  be  found  in  it  about  a  quarter  of  an  inch  in 
front  of  the  ear  (Fig.  345).  The  temporal  vein  accom- 
panies the  artery  and  lies  nearer  to  the  ear,  and  in  some 
cases  the  auric ulo-temporal  nerve  is  in  close  relation  to 


Fig.  ?>44. 


Fig.  345. 


Ligation  of  the  occipital  artery. 
(Skey.) 


Ligation  of  the  temporal  artery. 
(Skey.) 


the  artery.  The  needle  should  be  passed  from  behind 
forward. 

Ligation  of  the  Axillary  Artery. — The  axillary  artery 
extends  from  the  middle  of  the  clavicle  to  the  insertion  of 
the  teres  major  into  the  humerus ;  the  axillary  vein  lies 
upon  the  inner  side  and  in  front  of  the  artery.  The  axil- 
lary artery  is  tied  either  in  its  upper  portion,  just  below 
the  clavicle,  or  at  its  lower  portion  in  the  axilla. 

Axillary  Artery  below  the  Clavicle. — The  ineision  is  four 
inches  in  length  from  the  summit  of  the  coracoid  process 
inward  a  short  distance  below  the  clavicle  (Fig.  338,  E\ 
or  an  incision    three  inches  in   length,  commencing  at  a 


LIGATION  OF  THE  AXILLARY  ARTERY.         457 

point  one-half  an  inch  from  the  sternoclavicular  articu- 
lation, and  carried  obliquely  downward  toward  the  axilla. 

The  skin  and  subcutaneous  tissue  having  been  divided, 
the  deep  fascia  is  exposed  and  opened,  and  the  axillary 
artery  may  be  reached  by  following  the  intermuscular 
space  between  the  sternal  and  clavicular  fibres  of  the  pec- 
toralis  major  which  leads  upward  toward  the  clavicle  and 
to  the  pectoralis  minor ;  or  the  fibres  of  the  pectoralis 
major  being  exposed,  are  cut  through  and  the  costo-cora- 
coid  membrane  is  next  torn  through  with  a  director,  care 
being  taken  to  avoid  injury  of  the  cephalic  vein  at  the 
outer  portion  of  the  wound  ;  the  pectoralis  minor  is  now 
seen,  and  after  separating  the  cellular  tissue  with  a  director 
the  axillary  vein  is  seen  crossing  from  the  upper  edge  of 
the  muscle  to  the  clavicle  ;  the  vein  almost  completely 
covers  the  artery,  which  is  exposed  by  drawing  the  vein 
inward.  The  needle  is  passed  around  the  artery  from 
within  outward. 

Axillary  Artery  in  the  Axilla. — The  incision  is  two  and 
a  half  inches  long,  started  at  the  upper  part  of  the  axilla 

Fig.  346. 


A.  Incision  for  axillary  artery  in  axilla.    B.  Incision  for  brachial  artery. 

(Stimson.) 

and  carried  down  the  arm  at  the  edge  of  the  coraco- 
brachialis  muscle  (Fig.  346,  A).  The  skin  only  is  divided 
in  the  first  incision.  The  deep  fascia  is  then  picked  up 
and  divided  upon  a  director.  As  soon  as  the  fibres  of  the 
inner  border  of  the  coraco-brachialis  muscle  are  exposed 
and  held  aside  by  a  retractor,  the  operator  will  see  the 


458 


OPERA  TIONS. 


median  nerve,  the  musculocutaneous  nerve,  and  the  axil- 
lary artery.     To  the  inner  side  of  the  artery  are  the  axil- 


Fig.  347. 


Relations  of  right  axillary  artery  in  axilla.    (Esmarch.) 
Fig.  348. 


Relations  of  right  brachial  artery  at  middle  of  arm.     (Esmarch. 


lary  vein,  ulnar  and  internal  cutaneous  nerves  (Fig.  347). 
The  needle  should  be  passed  around  the  artery  from  the 
vein  toward  the  coraco-brachialis  muscle. 


LIGATION  OF  THE  RADIAL  ARTERY.  459 

Ligation  of  the  Brachial  Artery. — The  incision  is 
three  inches  long  at  the  middle  of  the  arm,  on  a  line  corre- 
sponding to  the  inner  edge  of  the  biceps  muscle  (Fig. 
346,  B).  The  skin  and  cellular  tissue  having  been  divided, 
care  being  taken  not  to  injure  the  basilic  vein,  which  should 
be  displaced  posteriorly,  the  deep  fascia  is  next  cut  through 
and  the  fibres  of  the  biceps  muscle  are  exposed  (Fig.  348)  ; 
this  muscle  should  be  drawn  forward  and  the  sheath  of 
the  vessels  enclosing  the  artery,  veins,  and  median  nerve 
exposed  ;  the  sheath  having  been  opened,  the  median  nerve 
is  pressed  aside  and  the  artery  is  separated  from  its  veins, 
and  the  needle  is  passed  from  the  side  of  the  nerve  around 
the  vessel.  In  ligating  the  brachial  artery  the  occasional 
high  division  of  the  vessel  must  be  borne  in  mind. 

Brachial  Artery  at  Bend  of  the  Elbow. — The  incision  is 
two  inches  in  length,  along  the  inner  border  of  the  tendon 

Fig.  349. 

Tendinous  aponeurosis 
divided. 


Ligation  of  the  brachial  artery  at  the  bend  of  the  elbow.    (Bryant.) 

of  the  biceps  muscle.  Divide  the  skin,  superficial  fascia, 
and  the  bicipital  aponeurosis,  under  which  the  artery  will 
be  exposed,  resting  upon  the  brachialis  anticus  muscle 
(Fig.  349).  The  median  nerve  is  to  the  inner  side  and 
some  distance  from  the  artery.  The  needle  should  be 
passed  around  the  vessel,  after  isolating  the  veins,  from 
within  outward. 

Ligation  of  the  Radial  Artery. — The  radial  artery 
extends  in  a  straight  line  from  a  point  half  an  inch  below 


460 


OPERATIONS. 


the  centre  of  the  fold  of  the  elbow  to  the  inner  side  of  the 
styloid  process  of  the  radius. 

The   radial  artery  may  be  tied  at  its  upper,  middle,  or 
lower  third,  or  at  the  root  of  the  thumb. 


Fig.  350. 


Fig.  351. 


tj\ 


Relations  of  right  radial  artery  in  the  upper 
third  of  the  forearm.   (Esmarch.) 

Fig.  352. 


Line  of  incision  for — A.  Radial  artery 
in  upper  third.  B.  Radial  artery  in 
lower  third.  C.  Ulnar  artery  in  upper 
third.  D.  Ulnar  artery  in  lower  third. 
(Stimson.) 


Relations  of  right  radial  artery  above 
the  wrist.     (Esmarch.) 


Radial  Artery  in  the  Upper  Third  of  the  Forearm. — The 
incision  for  the  radial  artery  at  its  upper  third  is  two  and 
a  half  inches  in  length  on  a  line  drawn  from  the  middle 
of  the  bend  of  the  elbow  to  the  ulnar  side  of  the  styloid 
process  of  the  radius ;  the  incision  should  begin  one  and  a 
half  inches  below  the  bend  of  the  elbow  (Fig.  350,  A). 
Divide  the  skin  and  superficial  fascia,  avoiding  the  super- 


LIGATION  OF  THE   ULNAR  ARTERY.  46l 

ficial  veins.  When  the  deep  faseia  is  exposed,  find  the 
edge  of  the  supinator  longus  muscle  and  divide  the  apo- 
neurosis along  its  ulnar  side,  and  expose  the  fibres  of  the 
pronator  radii  teres  muscle.  The  vessel  lies  in  the  inter- 
space between  these  muscles  surrounded  by  adipose  tissue, 
and  upon  being  exposed  the  veins  should  be  isolated  and 
the  needle  passed  from  without  inward.  The  radial  nerve 
lies  so  far  external  to  the  artery  that  it  is  not  often  ex- 
posed in  the  operation  (Fig.  351). 

Radial  Artery  in  the  Middle  Third  of  the  Forearm. — The 
incision  is  two  inches  in  length,  following  the  same  line  as 
that  for  the  upper  third  of  the  artery.  After  dividing 
the  skin,  superficial  and  deep  fascia,  the  artery  is  found 
in  the  interspace  between  the  flexor  carpi  radialis  on  the 
inner  side  and  the  supinator  longus  on  the  outer  side ; 
the  radial  nerve  at  this  part  of  the  arm  is  in  close  relation 
with  the  vessel  to  the  radial  side,  and  the  needle  should 
be  passed  around  the  artery  from  without  inward. 

Radial  Artery  in  the  Lower  Third  of  the  Forearm. — The 
incision  is  two  inches  in  length,  following  the  same  line 
(Fig.  350,  B\  ending  one  inch  above  the  wrist.  The 
skin,  superficial  and  deep  fascia  being  divided,  the  artery 
will  be  found  between  the  tendon  of  the  flexor  carpi 
radialis  on  the  inner  side  and  the  tendon  of  the  supinator 
longus  on  the  outer  side  (Fig.  352).  The  veins  being 
separated,  the  needle  may  be  passed  in  either  direction. 

Radial  Artery  at  the  Root  of  the  Thumb.— The  radial 
artery  may  also  be  tied  at  the  root  of  the  thumb.  The 
incision  is  one  inch  in  length  between  the  tendons  of 
the  extensor  ossis  metacarpi  pollicis  and  extensor  primi 
internodii  pollicis  on  the  outer  side,  and  the  tendon  of  the 
extensor  secundi  internodii  pollicis  on  the  inner  side.  The 
skin  and  superficial  fascia  being  divided  and  the  radial 
vein  being  displaced,  the  deep  fascia  is  opened  and  the 
artery  is  exposed  at  the  bottom  of  the  wound ;  the  needle 
may  be  passed  in  either  direction. 

Ligation  of  the  Ulnar  Artery. — The  ulnar  artery  is 
tied  at  the  junction  of  the  upper  and  middle  thirds  of  the 
forearm  and  at  the  lower  third. 


462 


OPERATIONS. 


Ulnar  Artery  at  the  Junction  of  the  Upper  and  Middle 
Thirds  of  the  Forearm. — The  incision  is  three  inches  in 
length,  starting  four  inches  below  the  internal  condyle  of 
the  humerus  on  a  line  passing  from  the  internal  condyle  of 
the  humerus  to  the  outer  border  of  the  pisiform  bone 
(Fig.  350,  C).  Divide  the  skin  and  superficial  fascia, 
and  when  the  deep  fascia  has  been  exposed  and  the  in- 
terspace between  the  flexor  carpi  ulnaris  and  the  flexor 
sublimis  digitorum  appears,  enter  this  interspace  and  raise 
the  flexor  sublimis  digitorum  and  work  transversely  across 
the  arm.     The  artery  will  be  found  resting  upon  the  deep 

Fig.  353. 


Relations  of  the  right  ulnar  artery  at  upper  third  of  the  forearm.    (Esmarch.) 

flexor,  with  the  ulnar  nerve  to  the  ulnar  side.  The  needle 
should  be  passed  from  the  nerve  around  the  arterv  (Fier. 
353). 

Ulnar  Artery  in  the  Lower  Third  of  the  Forearm. — The 
incision  is  two  inches  in  length,  a  little  to  the  radial  side 
of  the  tendon  of  the  flexor  carpi  ulnaris,  which  is  attached 
to  the  pisiform  bone,  ending  an  inch  above  the  wrist  (Fig. 
350,  D).  Divide  the  skin  and  superficial  fascia  and  open 
the  deep  fascia;  the  artery  will  be  exposed  with  its 
accompanying  veins,  between  the  tendons  of  the  flexor 
carpi  ulnaris  and  flexor  sublimis  digitorum,  the  ulnar 
nerve  being  to  the  ulnar  side  of  the  vessel.     The  needle 


LIGATION  OF  THE  COMMON  ILIAC  ARTERY.    463 

should  be  passed  from  within  outward  to  avoid  the  nerve 
(Fig.  354). 

Fig.  3o4. 


Relations  of  right  ulnar  artery  above  the  wrist.     (Esmarch.) 


Ligation  of  the  Interosseous  Artery. — The  incision  is 
similar  to  that  employed  in  the  ligation  of  the  ulnar  artery 
in  its  upper  third. 

Ligation  of  the  Abdominal  Aorta. — The  incision  is  in 
the  linea  alba  from  a  point  three  inches  above  the  umbili- 
cus to  a  point  three  inches  below  it.  The  superficial 
structures  being  divided,  the  peritoneum  is  opened  upon  a 
director,  and  the  intestines  are  pressed  aside  and  the  aorta 
is  exposed,  covered  by  peritoneum,  with  the  filaments  of 
the  sympathetic  nerve  resting  upon  it  and  the  vena  cava 
to  the  right  side.  Tear  through  the  peritoneum  and  pass 
the  needle  from  right  to  left  around  the  vessel.  After 
tying  the  ligature  the  ends  should  be  cut.  short  and  the 
external  wound  should  be  closed  as  in  the  ordinary  lapar- 
otomy wound. 

The  vessel  may  also  be  exposed  by  an  incision  along 
the  anterior  border  of  the  quadratus  lumborum  muscle, 
from  the  last  rib  to  the  crest  of  the  ilium.  The  skin, 
lumbar  muscles,  and  fascia  transversalis  being  divided, 
the  wound  is  held  open  with  blunt  hooks,  so  that  the 
retroperitoneal  space  is  exposed  and  the  aorta  brought 
into  view.  The  vessel  being  separated  from  the  vena  cava 
and  nerves,  the  needle  is  passed  around  it  and  the  ligature 
applied. 

Ligation  of  the  Common  Iliac  Artery. — The  aorta 
divides  into  the  two  common   iliac  arteries   on  the    left 


464 


OPERATIONS. 


side  of  the  fourth  lumbar  vertebra,  and  these  arteries  are 
usually  about  two  inches  in  length,  and  bifurcate  opposite 
the  sacro-iliac  synchondrosis  to  form  the  internal  and 
external  iliac  arteries ;  the  length  of  the  common  iliac 
artery,  however,  may  vary  considerably,  being  three  or 
four  inches  in  some  cases. 

The  incision  for  ligation  of  the  common  iliac  artery  is 
four  to  six  inches  in  length,  beginning  one-half  inch  above 
the  middle  of  Poupart's  ligament,  and  is  carried  outward, 
curving  upward  after  passing  the  anterior  superior  spine 
of  the  ilium  (Fig.  355,  ^1). 

Fig.  355. 


C  1 


Lines  of  incision  for— A.  Common  iliac  artery.    B.  External  iliac  artery. 
C.  Femoral  artery  in  Scarpa's  triangle.    (Stimson.) 

Divide  the  skin,  superficial  fascia,  and  aponeurosis  of 
the  external  oblique  muscle,  and  then  divide  the  fibres 
of  the  internal  oblique  and  transversalis  muscles  upon  a 
director  and  expose  the  transversalis  fascia.  This  is 
opened  at  the  lower  part  of  the  wound,  and  the  finger 
is  introduced  and  the  peritoneum  pressed  back ;  the 
opening  in  the  transversalis  fascia  is  next  enlarged,  and 
the  peritoneum  is  carefully  drawn  inward  and  upward 
with  the  fingers  toward  the  inner  edge  of  the  wound. 
The  operator  next  feels  for  the  external  iliac  artery,  and 
passes  the  finger  along  this  until  the  common  iliac  artery 


LIGATION  OF  THE  INTERNAL  ILIAC  ARTERY.   465 

is  reached.  The  loose  cellular  tissue  in  which  it  is  im- 
bedded is  next  separated,  and  the  needle  is  passed  from 
within  outward,  to  avoid  the  common  iliac  vein  (Fig. 
356),  which  on  the  left  side  lies  on  the  inner  side  of  the 
artery,  and  on  the  right  side  lies  behind  the  artery.  The 
ureter  generally  remains  attached  to  the  peritoneum  ;  if 
not,  it  is  seen  crossing  the  bifurcation  of  the  common  iliac 

Fig.  356. 


Ligation  of  the  common  iliac  artery.    (Liston.) 

with  the  genito-crural  nerve  ;  care  should  be  taken  to 
avoid  injury  of  these  structures. 

Transperitoneal  Method. — The  common  iliac  artery  may 
also  be  exposed  and  tied  by  an  incision  made  over  the 
artery  through  the  abdominal  wall  opening  the  peritoneal 
cavity :  the  vessel  being  tied,  the  ends  of  the  ligature  are 
cut  short,  and  the  external  wound  is  closed  in  the  same 
manner  as  that  resulting  from  exposure  of  the  abdom- 
inal aorta  by  incision  through  the  peritoneum. 

Ligation  of  the  Internal  Iliac  Artery. — The  incision 
is  in  the  same  line  as  for  the  common  iliac  artery,  but  it 

30 


466 


OPERATIONS. 


need  not  be  quite  so  long  (Fig.  355,  A).  The  peritoneum 
being  exposed,  it  is  pushed  upward  and  inward,  and  the 
internal  iliac  artery  is  exposed.  The  vessel  is  carefully 
isolated  from  the  vein,  which  lies  behind  and  on  the  inner 
side,  and  the  needle  is  passed  from  within  outward. 

The  transperitoneal  method  may  also  be  employed  in 
exposing  and  ligating  this  vessel. 

Ligation  of  the  External  Iliac  Artery. — The  incision 
is  three  or  four  inches  in  length,  half  an  inch  above  the 
middle  of  Poupart's  ligament,  made  at  first  parallel  to  it 

Fig.  357. 


Relations  of  the  right  external  iliac  artery.    (Esmarch.) 

and  then  curved  upward  (Fig.  355,  B).  The  tissues  of  the 
abdominal  wall  being  divided  and  the  peritoneum  exposed, 
it  is  pushed  upward  and  inward  in  the  same  manner  as 
for  exposure  of  the  common  iliac  artery.  The  artery  lies 
at  the  inner  border  of  the  psoas  muscle,  the  vein  on  its 
inner  side  and  the  anterior  crural  nerve  covered  by  the 
iliac  fascia  on  the  outer  side;  the  genito-crural  nerve 
passes  obliquely  across  the  artery  (Fig.  357).  The  needle 
should  be  passed  from  within  outward. 


LIGATION  OF  Till-    ITDIC  ARTERY. 


467 


The  transperitoneal  method  may  also   be  employed  in 

lijjCiitiiiLi:  this  vessel. 

1  Ligation  of  the  Gluteal  Artery.  The  incision  is  three 
or  four  inches  in  length,  from  the  posterior  superior  spinous 
process  of  the  ilium  to  a  point  midway  between  the  tuber 
ischii  and  the  great  trochanter  (Fig.  358,  A).  After  divis- 
ion of  the  skin  and  fascia,  the  fibres  of  the  gluteus  maxi- 
mus  muscle  are  separated  and  held  apart,  the  deep 
fascia  is  divided,  and  the  artery  should  then  be  sought  for 
above  the  pyriformis  muscle  at  the  upper  border  of  the 

Fig.  358. 


Lines  for— A.  Gluteal  artery.  B.  Sciatic  and  internal  pudic  arteries.    (Stimson.) 


great  sacro-sciatic  notch.  It  is  accompanied  by  large 
veins,  injury  to  which  should  be  avoided  in  exposing  the 
artery  and  passing  the  needle. 

Ligation  of  the  Sciatic  and  Internal  Pudic  Arteries. 
— The  incision  is  three  or  four  inches  in  length,  a  little  lower 
than  that  emploved  for  exposure  of  the  gluteal  artery  (Fig. 
358,  B).  Divide  the  skin,  superficial  fascia,  and  fibres  of 
the  gluteus  maximus  muscle  and  deep  fascia,  and  search 
for  the  vessels  as  they  leave  the  great  sciatic  notch  at  the 


468 


OPERA  TIONS. 


lower  edge  of  the  pyriformis  muscle.  The  internal  pudic 
artery  enters  the  pelvis  through  the  lesser  sciatic  notch, 
lying  on  the  inner  side  of  the  sciatic  artery  during  its  pas- 
sage over  the  spine  of  the  ischium.  The  vessels  are  isolated 
and  the  needle  is  passed  so  as  to  avoid  injury  of  the  veins. 

Ligation  of  the  Femoral  Artery. — The  femoral  artery 
may  be  ligated  just  below  Poupart's  ligament,  at  the  apex 
of  Scarpa's  triangle,  at  the  middle  of  the  thigh,  or  in 
Hunter's  canal. 

Femoral  Artery  below  Poupart's  Ligament. — The  incision 
begins    midway    between    the    anterior  superior    spinous 

Fig.  359. 


Relations  of  the  right  femoral  artery  below  Poupart's  ligament.     (Esmarch.) 

process  of  the  ilium  and  the  symphysis  pubis,  one-fourth 
of  an  inch  above  Poupart's  ligament,  and  extends  two 
inches  downward.  Divide  the  skin  and  superficial  fascia 
and  the  deep  fascia  so  as  to  expose  the  sheath  of  the 
vessels ;  open  this  one-half  an  inch  below  Poupart's  liga- 
ment and  isolate  the  femoral  artery  from  the  femoral  vein 
which  lies  to  the  inner  side ;  the  anterior  crural  nerve  lies 
to  the  outer  side.  Pass  the  needle  from  within  outward 
(Fig.  359). 


LIGATION  OF  THE  FEMORAL  ARTERY.         460 

Femoral  Artery  at  the  Apex  of  Scarpa's  Triangle. — The 
incision  is  three  inches  long,  the  centre  of  which  should  be 
a  little  above  the  point  where  the  sartorius  muscle  crosses 
a  line  drawn  from  the  middle  of  Pou  part's  ligament  to 
the  inner  condyle  of  the  femur  (Fig.  -3(30).  Divide  the 
skin,  superficial  and  deep  fascia,  avoiding  the  internal 
saphenous  vein,  and  expose  the  edge  of  the  sartorius 
muscle,  which  may  be  recognized  by  the  direction  of  its 
fibres.  This  muscle  is  drawn  outward  and  the  sheath  of 
the  vessels  is  exposed  and  opened;  the  vein  lies  on  the 
inner  side  and  somewhat  behind  the  artery,  and  the  long 

Fig.  360. 


'% 


i  *>■ 


Lines  of  incision  for  the  femoral  artery.    (Stimson.) 

saphenous  nerve  is  on  the  outer  side  (Fig.  361).  Pass  the 
needle  from  within  outward. 

Femoral  Artery  in  the  Middle  of  the  Thigh. — The  incision 
is  in  the  line  above  mentioned,  its  centre  being  a  little 
above  the  middle  of  the  thigh.  Divide  the  skin,  super- 
ficial and  deep  fascia,  and  expose  the  sartorius  muscle, 
which  is  drawn  outward  after  the  leg  has  been  flexed  ;  the 
sheath  of  the  vessels  is  exposed  and  opened  ;  the  long 
saphenous  nerve  lies  upon  the  artery  and  the  femoral  vein 
lies  behind  the  artery  ;  the  saphenous  vein  lies  more  super- 
ficially and  internal  to  the  vessel.  Pass  the  needle  from 
within  outward  (Fig.  362). 

Femoral  Artery  in  Hunter's  Canal. — The  incision  is  three 


470 


OPERATIONS. 


inches  in  length  along  the  tendon  of  the  adductor  magnus, 
the  centre  of  which  is  at  the  junction  of  the  lower  and 
middle  thirds  of  the  thigh  (Fig.  360).  Divide  the  skin, 
superficial  and  deep  fascia,  care  being  taken  not  to  injure 
the  internal  saphenous  vein,  which  should  be  displaced, 
and  expose  the  sartorius  muscle,  which  should  be  displaced 
downward,  and  expose  the  aponeurosis  which  forms  the 
anterior  Avail  of  the  vascular  canal ;  this  should  be  opened 
upon  a  director,  and  the  artery  uncovered  and  separated 


Fig.  361. 


Fig.  3G2. 


Relations  of  the  right  femoral 
artery  at  the  apex  of  Scarpa's 
triangle.     (Esmarch.) 


Relations  of  the  right  femoral  ar- 
tery in  the  middle  of  the  thigh. 
(Esmarch.) 


from    the    vein    which    lies    upon    the    outer    side.     The 
needle  is  passed  from  without  inward. 

Ligation  of  the  Popliteal  Artery.— The  incision  is 
three  or  four  inches  in  length,  along  the  external  border 
of  the  semi-membranosus  muscle.  Divide  the  skin  and 
superficial  fascia,  taking  care  not  to  injure  the  saphenous 
vein,  and  open  the  deep  fascia.  The  edges  of  the  wound 
being  held  apart,  the  adipose  tissue  is  broken  up  with  a 
director,  and  the  internal  popliteal  nerve  will  first  be  ex- 
posed, and  the  next    vein — both  external  to  the  artery 


LIGATION  OF  THE  ANTERIOR   TIBIAL  ARTERY.  471 

(Fig.  363).     The  artery  is  isolated  and  the  needle  passed 

from  without  inward. 

Fig.  3G3. 


Relations  of  the  right  popliteal  artery.    (Esmarch.) 

Ligation  of  the  Anterior  Tibial  Artery. — The  ante- 
rior tibial  artery  may  be  tied  in  the  upper,  middle,  and 
lower  thirds  of  the  leg ;  the  general  direction  of  the  artery 
corresponds  with  a  line  drawn  from  the  middle  of  the 
space  between  the  head  of  the  fibula  and  the  tubercle  of 
the  tibia  to  the  middle  of  the  anterior  intermalleolar  space. 

Anterior  Tibial  Artery  in  the  Upper  Third  of  the  Leg. — 
The  incision  is  two  and  a  half  to  three  inches  in  length, 
one  and  one-fourth  inches  external  to  the  spine  of  the 
tibia.  Divide  the  skin  and  superficial  fascia,  and  when 
the  deep  fascia  is  exposed  open  it  on  a  line  corresponding 
to  the  intermuscular  space  between  the  tibialis  anticus  and 
the    extensor   longus    digitorum    muscles.      Separate   the 


472 


OPERATIONS. 


muscles  and  work  down  in  this  interspace  until  the  artery 
is  found  Avith  a  vein  on  either  side  of  it,  and  the  anterior 
tibial  nerve  externally  (Fig.  364).  The  needle  should  be 
passed  from  without  inward  after  isolating  the  veins. 


Fig.  364. 


Ligation  of  the  anterior  tibial  artery  at  its  upper  third.    (Stimson.) 

Anterior  Tibial  Artery  at  its  Middle  Third. — The  incision 
is  three  inches  in  length  in  the  same  line  as  that  for  the 
upper  portion  of  the  vessel.  After  dividing  the  skin, 
superficial  and  deep  fascia,  the  interspace  between  the  tib- 
ialis anticus  and  the  extensor  longus  digitorum  muscles  is 
opened,  when  a  third  muscle  comes  into  view,  the  extensor 
proprius  pollicis.  The  artery  lies  between  the  extensor 
proprius  pollicis  and  the  tibialis  anticus  muscles ;  and  the 
anterior  tibial  nerve  is  to  the  outer  side.  The  veins  should 
be  isolated  and  the  needle  passed  from  without  inward. 

Anterior  Tibial  Artery  in  its  Lower  Third. — The  incision 
is  two  inches  in  length,  beginning  three  inches  above  the 
ankle-joint  on  the  line  of  the  artery.     Divide  the  skin, 


LIGATION  OF  THE  DORSALIS  PEDIS  ARTERY.  473 


superficial  and  deep  fascia,  and  seek  for  the  tendon  of  the 
extensor  proprius  pollicis  muscle,  the  second  tendon  from 
the  tibia.  The  artery  is  found  in  the  interspace  between 
this  tendon  and  the  tendon  of  the  extensor  longus  digito- 
rum  muscle,  the  nerve  being  to  the  outer  side.  The  veins 
are  isolated  from  the  artery,  and  the  needle  is  passed  from 
without  inward.  ,  . 

Ligation  of  the  Dorsalis  Pedis  Artery.— The  incision 
is  one  inch  in  length  on  a  line  drawn   from  the  middle  of 

Fig.  365. 


Extensor 
brevis  digitorum~^, 
muscle. 


Tendon  of 
—  extensor 
proprius 
pollicis. 


Ligation  of  the  dorsalis  pedis  artery.    (Bryant.) 

the  anterior  intermalleolar  space  to  a  point  midway  be- 
tween the  extremities  of  the  first  two  metatarsal  bones  or 
along  the  outer  border  of  the  tendon  of  the  extensor  pro- 
prius pollicis.  Divide  the  skin,  superficial  and  deep  fascia, 
and  the  artery  will  be  found  lying  next  to  the  inner  tendon 
of  the  short  extensor  muscle  of  the  toes  (Fig.  365>  The 
nerve  is  to  the  outer  side.  After  separating  the  veins  the 
needle  is  passed  from  without  inward. 


474 


OPERATIONS. 


Fig.  366. 


Ligation  of  the  Posterior  Tibial  Artery. — The  course 
of  the  posterior  tibial  artery  is  in- 
dicated by  a  line  drawn  from  the 
middle  of  the  popliteal  space  to  a 
point  midway  between  the  tendo- 
Achillis  and  the  internal  malleolus 
of  the  tibia. 

The  posterior  tibial  artery  may 
be  ligated  in  its  upper,  middle,  and 
lower  thirds. 

Posterior  Tibial  Artery  at  its 
Upper  Third. — The  incision  is  three 
and  a  half  inches  in  length,  one- 
half  inch  from  the  inner  edge  of 
the  tibia,  beginning  two  inches  from 
the  upper  edge  of  the  bone  (Fig. 
366).  Divide  the  skin  and  super- 
ficial fascia,  avoiding  large  super- 
ficial veins ;  next  open  the  deep 
fascia  and  detach  the  origin  of  the 
soleus  muscle  from  the  tibia,  and 
on  raising  it  the  under  surface  will 
present  a  white,  shining  sheath  of 
tendinous  material,  beneath  which 
will  be  seen  a  layer  of  fascia  cover- 
ing the  tibialis  posticus  muscle.  If 
search  is  made  toward  the  middle  of  the  leg  the  artery 
will  be  found  covered  by  the  intermuscular  fascia,  the 
nerve  being  to  the  outer  side.  The  needle  is  passed  from 
without  inward  after  the  veins  have  been  separated  from 
the  artery  (Fig.  367). 

Posterior  Tibial  Artery  at  its  Middle  Third. — The  incision 
is  two  and  a  half  inches  in  length,  parallel  with  the  inner 
edge  of  the  tibia  and  half  an  inch  from  its  border.  Divide 
the  skin,  superficial  and  deep  fascia,  and  the  inner  edge 
of  the  soleus  will  be  exposed  ;  press  this  outward,  when  the 
artery  with  its  veins  will  be  exposed,  also  the  posterior 
tibial  nerve  to  the  outer  side.  Pass  the  needle  from  with- 
out inward  after  separating  the  veins. 


Lines  of  incision  for  the 
posterior  tibial  artery. 
(Stimson.) 


LIGATION  OF  THE  POSTERIOR   TIBIAL  ARTERY.   475 

Fig.  367. 


Relations  of  the  right  posterior  tibial  artery  in  its  upper  third.    (Esmarch.) 

Fig.  368. 


Ligation  of  the  posterior  tibial  artery  behind  the  inner  malleolus.     (Bryant.) 

Posterior  Tibial  Artery  behind  the  Inner  Malleolus. — The 
incision  is  a  curved  one  two  inches  in  length,  midway  be- 
tween the  tendo-Achillis  and  the  internal  malleolus  (Fig. 


476  OPERATIONS. 

366).  Divide  the  skin  and  superficial  fascia,  then  lift 
the  deep  fascia  upon  a  director  and  open  it  freely,  when 
the  artery  will  be  exposed,  with  the  tendons  of  the  tibialis 
posticus  and  flexor  longus  digitorum  muscles  on  the  inner 
side  and  the  posterior  tibial  nerve  and  the  tendon  of  the 
flexor  longus  pollicis  muscle  on  the  outer  side  (Fig.  368). 
After  separating  the  veins  from  the  artery  the  needle 
should  be  passed  from  without  inward. 


PAET  VI. 

AMPUTATIONS 


The  term  amputation  is  now  generally  applied  to  the 
removal  of  a  limb,  and  this  may  be  effected  through  the 
bones,  when  the  operation  is  spoken  of  as  an  amputation 
in  the  continuity  of  the  limb  ;  or  it  may  be  removed 
through  its  joints,  when  it  is  known  as  an  amputation 
in  the  contiguity  or  a  disarticulation. 


Methods  of  Amputating. 


Amputations  may  be  performed  by  the  circular,  modi- 
fied circular  or  oval,  elliptical,  and  transfixion  methods. 
Teak's  method  bv  rectangular  flaps  is  also  employed. 

Circular  Method. — In  performing  an  amputation  by 
this  method  the  incision  of  the  skin  is  made  at  a  distance 
below  the  point  where  the  bone  is  to  be  divided.  An 
assistant  grasps  the  limb  and  draws  the  skin  evenly  and 
firmly  toward  the  root  of  the  part,  and  the  surgeon  passes 
the  heel  of  the  knife  well  into  the  tissues  and  makes  a  cir- 
cular sweep  around  the  limb,  completing  the  division  of 
the  skin  and  cellular  tissue  with  one  motion  of  the  knife 

(Fig.  369).  .  •■ 

The  second  incision  in  an  amputation  by  the  circular 
method  consists,  after  retraction  of  the  skin,  in  making  a 
circular  cut  through  all  of  the  tissues  down  to  the  bone 

(Fig.  370). 

The  third  step  in  an  amputation  by  this  method  consists, 

477 


478 


AMPUTATIONS. 

Fig.  369. 


Amputation  by  circular  method.    (Dkuitt.) 

after  retracting  the  skin  and  muscles  and  holding  them 
back  by  a  retractor,  in  the  division  of  the  bone  with  a  saw. 

Fig.  370. 


Division  of  muscles  in  circular  amputation.    (Smith.) 

Transfixion  Method. — This  is  a  variety  of  the  flap 
method,  the  flaps  being  cut  from  within  outward ;  they  may 
be  lateral  or  antero-posterior.  In  amputating  by  this  method 
the  surgeon  grasps  the  limb  and  enters  the  point  of  a  long 
knife  into  the  tissues  at  the  side  nearest  himself,  and  push- 


MODIFIED   CIRCULAR   OR   OVAL   METHOD.       479 

ing  it  across  and  round  the  bone  or  bones  brings  its  point 
out  through  the  skin  at  a  point  diametrically  opposite  its 
point  of  entrance.  He  then  shapes  the  flap  by  cutting 
downward  with  a  rapid  sawing  motion,  and  then  cuts 
obliquely  forward  until  all  the  tissues  are  divided.  The 
flap  being  turned  up,  he  re-enters  his  knife  at  the  same 
point  and  passes  it  on  the  other  side  of  the  bone  or  bones 
and  cuts  the  second  flap  in  the  same  manner  (Fig.  371).  A 
retractor  is  next  applied  and  the  bone  is  divided  with  a  saw. 

Fig.  371. 


Amputation  by  anteroposterior  flaps.    (Bryaxt.) 

Modified  Circular  or  Oval  Method. — In  this  form  of 
amputation  two  oval  antero-posterior  or  lateral  flaps  of 
skin  are  marked  out  by  incisions  and  dissected  up  to  the 
point  at  which  the  muscles  and  bone  are  to  be  divided. 
The  muscles  are  then  divided  close  to  the  base  of  the  flaps 
by  a  circular  sweep  of  the  knife,  and  the  operation  is 
completed  by  sawing  the  bones..  This  form  of  amputation 
is  at  present  widely  employed,  and  is  especially  to  be  recom- 
mended in  muscular  limbs  (Fig.  372V 

Elliptical  Method.  —This  is  a  form  of  the  oval  method 
of  amputation  which  is  employed  in  amputations  at  the 
knee-joint  and  elbow-joint,  the  incision  forming  an  ellipse, 


480 


AMPUTATIONS. 


Fig.  372. 


.4rjr 


Modified  circular  amputation.    (Skey.) 

coming  below  the  joint  on  the  front  or  outside  of  the  limb, 
the  resulting  flap  being  folded  upon  itself. 

Fig.  373. 


Teale's  method  of  amputation.    (Bryant.) 

Teale's  Method   by  Rectangular  Flaps. —  In  this 

method  of  amputation  two  flaps  are  made  of  unequal 
length  ;  the  incisions  are  so  planned  that  the  shorter  flap 
contains  the  main  vessel  or  vessels.     The  flaps  are  cut  of 


BIER'S  OSTEOPLASTIC  METHOD. 


481 


equal  width  and  the  length  of  the  long  flap  should  be  one- 
half  of  the  circumference  of  the  limb  at  the  point  where  the 
bone  is  to  be  divided ;  the  length  of  the  short  flap  should  be 
one-eighth  of  the  circumference  of  the  limb.  The  flaps  are 
cut  from  without  inward,  and  embrace  all  of  the  tissues 
of  the  limb  down  to  the  bone.  After  the  flaps  have  been 
dissected  up  the  bone  is  divided  with  a  saw,  and  the  long 
flap  is  folded  over  and  sutured  to  the  short  flap  (Fig.  373). 
The  disadvantage  of  this  method  of  amputation  is  that 
in  muscular  limbs  it  requires  the  bone  to  be  divided  at  a 
higher  point  than  would  otherwise  be  necessary. 

Bier's  Osteoplastic  Method.— To  provide  a  better 
bearing  surface  for  stumps,  Bier  has  recommended  an  osteo- 
plastic amputation.  It  may  be  employed  in  primary  ampu- 
tation or  in  cases  of  re-amputation.    In  amputating  the  leg 


Fig.  374. 


Fig.  375. 


Bier's  osteoplastic  amputation  of  the  Bier's  osteoplastic   amputation  of 

leg.  the  leg,  with  osteoperiosteal  flap  in 

position. 

by  this  method,  an  oval  flap,  composed  of  the  skin  and 
cellular  tissue  of  one-half  of  the  width  of  the  leg,  is  dis- 
sected to  the  point  where  the  bones  are  to  be  divided,  care 
being  taken  not  to  injure  the  periosteum.  A  rectangular 
flap  of  the  periosteum,  large  enough  to  cover  the  sawn 
surface  of  the  tibia  and  fibula,  is  next  marked  out  by  in- 
cisions, the  longitudinal  incisions  extending  a  little  beyond 
the  anterior  edge  of  the  tibia.     The  flap  is  then  reflected 

31 


482  AMP  VTA  TIONS. 

about  one-half  a  centimeter  from  the  transverse  incision, 
and  a  thin  lamella  of  hone  is  next  sawed  in  an  upward 
direction  with  a  fine  saw,  the  saw  being  turned  toward  the 
periosteum  at  its  upper  part  to  complete  the  bone  flap. 
This  flap  is  turned  so  as  to  cover  the  sawn  surface  of  the 
bones  and  secured  by  a  few  sutures  (Figs.  374,  375).  The 
amputation  is  completed  by  making  a  circular  incision  of 
the  tissues  on  the  posterior  aspect  of  the  leg  and  sawing 
the  bones  close  to  the  border  of  the  inverted  bone  flap. 

Periosteal  Flaps. — In  any  of  the  methods  of  amputa- 
tion previously  described  the  periosteum  may  be  dissected 
up  in  two  flaps  attached  to  the  muscles,  or  pushed  up  as 
a  sleeve  by  means  of  a  director  or  periosteotome  before  the 
bone  is  sawed.  This  procedure  is  most  easily  accomplished 
in  young  subjects.  When  these  flaps  are  made  and  are 
brought  together,  the  periosteum  covers  the  cut  surface 
of  the  bone,  to  which  it  soon  forms  adhesions. 

Instruments  Required  for  Amputations. — The  instru- 
ments required  for  amputations  are  knives  of  various 
shapes  and  sizes,  saws,  dissecting  forceps,  bone-forceps, 
artery  forceps,  tenacula,  haemostatic  forceps,  scissors,  peri- 
osteotomes,  tourniquets,  Esmarch's  bandage  and  strap, 
retractors,  ligatures,  sutures,  and  needles. 

Amputating  Knives. — The  knives  required  for  amputa- 
tions vary  according  to  the  method  of  amputation  and  the 

Fig.  376. 

Scalpel. 

part  to  be  amputated.  In  certain  amputations  a  scalpel 
(Fig.  376)  or  straight  bistoury  (Fig.  377)  may  be  used, 
while  in  other  cases  the  employment  of  amputating  knives 
of  various  sizes  will  be  found  more  satisfactory.  For 
amputations  of  the  thigh  a  knife  with  a  blade  of  eight  or 
nine  inches  is  generally  employed,  and  for  smaller  limbs  a 
knife  with  a  blade  of  six  or  seven  inches  in  length  ;  double- 
edged  catlins  are  employed  in  amputations  of  the  leg  and 


INSTRUMENTS  REQUIRED  FOR  AMPUTATIONS.  483 

forearm,  to  divide  the  interosseous  tissues  before  applying 
the  saw.     The  amputating  knives  now  employed  are  con- 

Fig.  377. 


Straight  bistoury. 


structed  with  solid  metal  handles,  so  that  they  may  be 
rendered  thoroughly  aseptic  by  immersion  in  boiling  water 
before  being  used  (Fig.  378). 


Fig.  37S. 


Amputating  knife  and  catlin. 

Amputating  Saws. — Several  kinds  of  amputating  saws 
are  in  general  use ;  one  with  a  blade  ten  inches  long  by 
two  and  a  half  inches  wide,  with  a  heavy  back  to  give  it 
additional  firmness,  is  a  very  good  variety  of  saw  (Fig. 
379).     For  amputations  about  the  foot  or  hand  a  narrow 

Fig.  379. 


Amputating  savr. 

saw  with  a  movable  back  will  be  found  very  convenient 
(Fio\  380).  A  bow  saw  with  a  metallic  handle  and  a  re- 
versible blade  is  a  very  useful  variety  of  saw,  as  it  can  be 
used  either  in  amputations  or  in  excisions,  and,  being  con- 


484 


AMPUTATIONS. 
Fig.  380. 


Small  amputating  saw. 

structed  entirely  of  metal,  it  can  be  easily  rendered  aseptic 
(Fig.  381). 

Fig.  381. 


-  \JBWXViWS, 


J5> 


Amputating  saw  with  reversible  blade. 

Bone-forceps,  or  Cutting  Pliers. — These  instruments  are 
used  in  smoothing  off  any  rough  edges  of  bone  left  after 
the  use  of  the  saw,  or  for  the  division  of  the  small  bones 
in  amputations  of  the  fingers  and  toes.  The  forceps  should 
be  from  ten  to  twelve  inches  in  length,  with  blades  from 
one  to  one  and  a  half  inches  in  length  (Fig.  382). 

Fig.  382. 


Bone-forceps,  or  cutting  pliers. 

Periosteotome. — The  periosteotome,  or  raspatory,  is  em- 
ployed for  dissecting  up  a  flap  of  periosteum,  which,  after 
sawing  the  bone,  is  drawn  down  over  the  sawed  end  of  the 
bone  (Fig.  383). 

Artery  Forceps  and  Tenacula. — These  instruments  are 
Hised  for  taking  up  the  vessels,  and  one  of  the  best  forms 


INSTRUMENTS  REQUIRED  FOR  AMPUTATIONS.   485 

Fig.  383. 


Periosteotome. 


of  artery  forceps  is  that  known  as  the  double-spring  artery 
forceps  (Fig.  229).  Tenacula  are  also  employed  for  the 
same  purpose  (Fig.  230).  Hemostatic  forceps  will  also  be 
found  most  useful  in  cases  of  amputation,  for  the  rapid 
control  of  hemorrhage  from  small  vessels  after  the  tourni- 
quet has  been  removed,  the  vessels  being  secured  by 
torsion  or  by  ligatures  before  the  haemostatic  forceps  are 
removed. 

Retractors. — These  consist  of  pieces  of  sterilized  muslin 
six  or  eight  inches  in  width,  one  end  of  which  is  split 

Fig.  384. 


Retractor  applied.     (Esmarch.) 


into  two  or  three  tails ;  the  former  variety  of  retractor  is 
employed  where  one  bone  is  divided,  as  in  amputations 


486 


AMPUTATIONS. 


of  the  arm  and  thigh  (Fig.  384),  and  the  latter  in  cases 
where  two  bones  are  divided,  as  in  amputations  of  the 
forearm  and  leg. 

Ligatures. —  The  best  material  to  employ  for  the  ligature 
of  vessels  is  plain  or  chromieized  catgut  or  sterilized  silk, 
the  preparation  of  which  has  been  described  (page  138). 

Sutures. — The  materials  employed  for  sutures  in  cases 
of  amputation  may  be  silkworm-gut,  catgut,  silk,  or  silver 
wire ;  deep  or  buried  sutures  of  catgut,  bringing  together 
the  edges  of  the  periosteal  flaps,  muscles,  and  fascia,  are 
often  employed  with  advantage  in  amputations  (Fig.  385), 
the  skin  flaps  being  brought  together  with  interrupted  or 


Fig.  385. 


Fig.  386. 


Deep  or  buried  sutures  of  muscles. 
(Esmarch.) 


Sutures  of  the  skin. 

(ESMARCH.) 


continuous  sutures  of  silk,  catgut,  silkworm-gut,  or  silver 
wire  (Fig.  386). 

Tourniquets. — For  the  control  of  hemorrhage  during 
amputation  the  Esmarch  apparatus  (Fig.  228)  or  Petit's 
tourniquet  (Fig.  222)  is  employed  ;  or  the  employment  of 
both  at  the  same  time  will  often  be  found  most  satisfactory. 
The  Esmarch  bandage  and  tube  being  applied,  after  re- 
moval of  the  bandage,  the  tourniquet  of  Petit  is  loosely 
applied  at  a  higher  point,  and  after  the  main  vessels  have 
been  secured  the  elastic  strap  is  removed,  and  the  tourni- 
quet is  screwed  down  and  controls  the  bleeding  until  the 
smaller  vessels  have  been  secured  by  ligatures.     Wyeth's 


DETAILS  OF  AN  AMPUTATION.  487 

pins  may  be  used  in  conjunction  with  the  elastic  strap  in 
amputations  at  the  hip-joint  and  shoulder-joint. 

Details  of  an  Amputation. — The  following  are  the 
steps  of  an  amputation  of  the  lower  part  of  the  thigh  : 

The  skin  is  first  thoroughly  cleansed  by  scrubbing  it  with 
turpentine,  soap  and  water,  and  alcohol.    It  is  then  washed 
with  a  solution  of  bichloride  of  mercury,  1  :  2000.     Provi- 
sion is  next  made  to  prevent  the  loss  of  blood  during  the 
operation  by  the  application   of  Esmarch's  bandage  and 
tube ;  the  bandage  being  removed  a  tourniquet  is  placed 
over 'the  femoral  artery  in  Scarpa's  triangle  and  loosely 
secured.     The  limb  is  again  washed  with  bichloride  solu- 
tion.   The  instruments  having  been  previously  thoroughly 
sterilized,  a    rubber  cloth  covered  with  sterilized  towels 
wrung  out  in  a  bichloride  solution  is  placed  under  the  limb. 
The  variety  of  amputation  having  been  decided  upon,  the 
flaps  are  cut  and  the  muscles  are  divided  down  to  the  bone ; 
the  periosteum  being  dissected  up,  a  two-tailed  retractor 
is  applied,  and  the  tissues  are  held  back  by  an  assistant 
while  the  surgeon  divides  the  bone  with  the  saw.     When 
the  bone  has  been  divided  the  retractor  is  removed.  ^  Irri- 
gation of  the  surface  of  the  wound  is  not  necessary  if  the 
operation  has  been  an  aseptic  one.     Sterilized  gauze  pads 
may  be  employed  to  wipe  away  the  blood.     The  femoral 
artery  and  vein  are  next  found  and  secured  with  ligatures, 
and  any  muscular  branches  which  can  be  found  are  also 
secured.    The  elastic  strap  is  removed  after  screwing  down 
the  tourniquet,  and  by  gradually  letting  up  the  pressure 
on   the  smaller  vessels  which  bleed,  they  are  picked  up 
with    artery  forceps  or  haemostatic    forceps  and  secured. 
After  all  bleeding  has  been  controlled  the  tourniquet  is 
removed.     If  there  is  much  oozing  from  the  smaller  ves- 
sels, irrigation  with  hot  saline  solution  or  sterilized  water 
may  be  employed ;  the  fluid  should  be  as  hot  as  the  hands 
of  the   operator    can    comfortably  stand,  which    will    act 
promptly  in    controlling   this  variety  of  bleeding.     The 
periosteal    flaps,    if  they  have    been    made,   are   brought 
together  by  two  or  three  catgut  sutures,  and  a  long  drain- 
age-tube is  next  introduced,  or  two  short  tubes  are  intro- 


488 


AMPUTATIONS. 


duced  at  either  extremity  of  the  wound  and  secured  by 
sutures  or  safety-pins.  Drainage  may  be  omitted,  but  I 
consider  it  wise  to  employ  it  in  major  amputations.  The 
muscles  and  tendons  should  next  be  brought  together  over 
the  face  of  the  stump  by  a  few  deep  or  buried  sutures  of 
catgut,  thereby  making  a  good  cushion  and  tending  to 
lessen  the  subsequent  muscular  atrophy,  and  the  skin  Haps 
should  then  be  brought  into  apposition  by  a  number  of 
interrupted  sutures  (Fig.  387).  The  surface  of  the  stump 
is  next  washed  with  salt  solution  or  sterilized  water,  and  a 

Fig.  387. 


Stump  showing  application  of  sutures  and  drainage-tubes.    (Smith.) 

number  of  layers  of  dry  sterilized  gauze  are  applied  over 
its  surface  and  over  the  gauze  dressing  a  number  of  layers 
of  sterilized  cotton  are  placed,  and  the  whole  dressing  is 
held  in  place  by  a  recurrent  bandage  of  the  stump. 

If  the  antiseptic  method  is  employed,  the  surface  of  the 
wound  is  irrigated  at  intervals  during  the  operation  with  a 
1  :  2000  bichloride  solution,  and  the  stump  is  dressed  with 
moist  or  dry  bichloride  gauze  and  bichloride  cotton. 

Re-dressing  of  Amputations. — The  first  dressing  of 
an  amputation,  if  strict  antiseptic  precautions  have  been 


BE-DRESSING   OF  AMPUTATIONS.  489 

observed  at  the  time  of  operation,  need  not,  as  a  rule,  be 
made  for  a  week  or  ten  days,  except  in  cases  where  the 
oozing  is  so  profuse  as  to  soak  the  dressings,  or  where  con- 
secutive hemorrhage  has  occurred,  or  the  patient's  condi- 
tion shows  that  the  wound  is  not  running  an  aseptic  course. 
The  re-dressing  of  a  stump  can  be  accomplished  without 
pain  to  the  patient  if  the  surgeon  and  his  assistants  are 
careful  in  their  manipulations. 

The  dressings  to  be  applied,  the  solutions  for  irrigation, 
and  the  instruments  required  should  be  prepared  and  at 
hand  before  the  stump  is  exposed.  The  surgeon  and  his 
assistants  should  wash  their  hands  carefully,  and  then  soak 
them  in  a  1  :  2000  bichloride  solution.  The  bandage 
retaining  the  dressings  to  the  stump  should  be  divided 
with  bandage  scissors  without  lifting  the  stump  from  the 
pillow  upon  which  it  rests.  After  the  bandage  has  been 
divided  and  turned  aside,  the  gauze  dressing  is  next 
unfolded  and  turned  down  ;  an  assistant  now  slips  his 
hands  under  the  stump  and  gently  raises  it  from  the  dress- 
ings, and  at  the  same  time  a  rubber  cloth  covered  with 
sterilized  towels  or  towels  which  have  been  wrung  out  in  a 
1  :  2000  bichloride  solution  is  slipped  under  the  stump  and 
the  soiled  dressings  are  removed.  If  the  dressings  are 
adherent  at  the  line  of  incision,  irrigation  with  saline  solu- 
tion or  distilled  water  may  be  employed  to  soften  them  and 
facilitate  their  removal. 

If  the  wound  is  aseptic  and  there  seems  to  be  no  further 
indication  for  the  use  of  the  drainage-tubes,  they  may  be 
removed.  The  sutures  are  next  examined,  and  if  the 
wound  is  firmly  healed  alternate  sutures  may  be  removed ; 
if  catgut  or  silkworm-gut  sutures  have  been  used,  they 
need  not  be  disturbed  at  this  dressing,  and  their  removal 
may  be  postponed  until  a  subsequent  dressing. 

The  wound  should  next  be  covered  with  a  sterilized 
gauze  dressing  consisting  of  a  number  of  layers,  and  over 
this  several  layers  of  sterilized  cotton,  and  the  dressings 
should  be  held  in  place  by  a  recurrent  bandage  of  the 
stump.  If  the  antiseptic  method  has  been  employed  the 
stump  may  be  irrigated  with  a  1  :  2000  bichloride  solution 


490 


AMPUTATIONS. 


and  a  dressing  of  bichloride  gauze  and  cotton  used  to 
cover  the  stump.  The  assistant  should  hold  the  stump 
firmly,  to  prevent  muscular  spasm,  and  after  the  dressings 
have  been  secured  it  should  be  placed  upon  a  clean  pil- 
low prepared  for  its  reception.  The  same  procedures  are 
adopted  at  subsequent  dressings ;  and  if  the  wound  has 
run  an  aseptic  course,  two  or  three  dressings,  at  most, 
will  be  required. 


AMPUTATIONS  OF  THE  HAND. 

Amputations  of  the  Fingers. — The  fingers  may  be 
amputated  in  the  continuity  of  the  phalanges  or  in  their 
contiguity,  and,  as  a  rule,  as  it  is  important  to  save  as  much 

Fig.  388. 


Amputation  of  a  finger  by  the  long  palmar  flap.     (After  Esmarch.) 

as  possible  of  the  finger,  the  former  method  is  generally  to 
be  employed  instead  of  disarticulation  at  a  higher  point. 
The  incision  should  be  so  planned  that  the  cicatrix  does 
not  occupy  the  palmar  surface  ;  the  larger  flap  should, 
therefore,  be  taken  from  the  palmar  aspect  of  the  finger. 
In  amputating  the  phalanges  of  the  fingers  in  their  con- 
tinuity, the    circular   method    (Fig.  392,  B)    or   a    short 


AMPUTATION  OF  THE  FINGER. 


491 


dorsal  flap  and  a  long  palmar  flap  may  be  employed.  Tn 
disarticulating  a  phalanx  it  is  best  to  enter  the  joint  with  a 
narrow  knife  from  the  dorsal  side,  and  after  having 
carried  it  through  the  joint,  to  cut  a  long  palmar  flap, 
keeping  close  to  the  bone  (Fig.  388).  In  locating  the 
position  of  the  phalangeal  joints,  it  is  well  to  remember  that 
the  prominence  of  the  knuckle  when  the  finger  is  flexed  is 
formed  entirely  of  the  head  of  the  proximal  and  not  of  the 


Fig.  389. 


Fig.  390. 


Phalanges  flexed. 


Guides  to  articulations  of  the  fingers,  a.  head 
of  metacarpal  bone  :  b,  metacarpophalangeal 
articulation  :  c,  relation  of  palmar  fold  to  articu- 
lation :  d,  e,  interphalangeal  articulation  ;  /,  ar- 
ticulation of  distal  phalanx.     i^Smith.) 


base  of  the  distal  phalanx  (Fig.  389),  and  also  that  the  folds 
on  the  palmar  surface  of  the  finger  do  not  correspond 
exactly  to  the  joints  (Fig.  390). 

Amputation  of  the  Finger  through  the  Metacarpo- 
phalangeal Articulation. — In  this  variety  of  amputation 
an  incision  is  made  from  a  point  on  the  dorsal  surface  of 
the  metacarpal  bone  a  quarter  of  an  inch  above  the  articu- 
lation, which  is  carried  through  the  interdigital  web  and 
back  upon  the  palmar  surface  to  a  point  a  quarter  of  an  inch 
above  the  flexor  fold  (Fig.  392,  C).    A  similar  incision  be- 


492 


AMPUTATIONS. 


ginning  and  ending  at  the  same  points  is  made  upon  the 
opposite  side  of  the  finger.  The  flaps  are  dissected  back, 
and  the  lateral  ligaments,  tendons,  and  remainder  of  the 
capsule  are  divided  (Fig.  391).  The  finger  may  also  be 
amputated  at  the  metacarpo-phalangeal  joint  by  making 
an  incision  on  one  side  and  dissecting  the  flap  back  to  the 
joint,  then  dividing  the  lateral  ligament,  opening  the  joint 

Fig.  391. 


Racket-shaped  incision  for  amputation  of  the  finger  at  the  metacarpo- 
phalangeal joint.    (After  Rotter.) 

and  carrying  the  knife  across  this,  dividing  the  tendons 
and  lateral  ligament  on  the  other  side  and  cutting  a  flap 
from  within  outward. 

Kemoval  of  the  head  of  the  metacarpal  bone  if  desired 
may  be  accomplished  by  the  use  of  cutting  pliers  (Fig. 
393)  ;  but,  as  a  rule,  this  procedure  is  not  to  be  recom- 
mended, for,  although  the  deformity  is  lessened,  the 
strength  of  the  hand  is  diminished. 


AMPUTATIONS  OF  THE  METACARPAL  BONES.  493 

In  amputating  the  little  and  index  fingers  a  full  lateral 
flap  may  be  cut  on  the  free  side,  and  an  incision  is  next 
carried  across  the  palmar  surface  to  the  angle  of  the  web, 
and  thence  back  to  the  joint,  which  is  opened  and  the  dis- 
articulation effected  (Fig.  392,  E). 

Fig.  392. 


A.  Disarticulation  of  distal  phalanx:  palmar  flap.  B.  Amputation  in  con- 
tinuity by  a  circular  flap.  C.  Metacarpophalangeal  disarticulation.  D.  Ampu- 
tation of  metacarpal  bone  in  continuity.  E.  Disarticulation  of  little  finger. 
F.  Disarticulation  of  fifth  metacarpal  "bone.  G.  Amputation  at  the  wrist, 
circular.    H.  Amputation  at  the  wrist,  lateral.     (Stimson.) 


Amputations  of  the  Metacarpal  Bones. — In  ampu- 
tating the  metacarpal  bones  it  is  advisable  to  leave  the 
carpal  ends  of  the  bones  to  avoid  opening  the  wrist-joint, 
except  in  the  case  of  the  first  and  fifth  metacarpal  bones, 
which  do  not  communicate  with  the  others  and  with  the 
synovial  sacs. 

The  incisions  for  the  removal  of  the  metacarpal  bones 


494 


AMPUTATIONS. 


are  the  same  as  for  the  removal  of  a  finger  at  the  meta- 
carpo-phalangeal  joint,  the  incision  being  prolonged  back- 
ward as  far  as  necessary  over  the  dorsal  surface  of  the 
bone  (Fig.  392,  D.)  After  the  metacarpal  bone  has  been 
bared  for  a  sufficient  distance,  it  is  cut  through  with  bone- 
pliers  or  disarticulated,  and  the  distal  end  is  raised  from 
its  bed  and  carefully  separated  from  the  soft  parts,  care 
being  taken  to  avoid  injury  of  the  structures  of  the  palm 

of  the  hand. 

Fig.  393. 


Removal  of  the  head  of  a  metacarpal  bone.    (Skey.) 


In  amputating  the  fifth  metacarpal  bone,  the  incision 
should  be  made  along  the  inner  border  of  the  hand  and 
carried  down  to  the  bone  between  the  skin  and  the  ab- 
ductor minimi  digiti  muscle  (Fig.  394).  The  lower  end 
of  the  incision  passes  over  the  knuckle  to  the  web  of  the 
finger,  and  backward  under  the  palmar  surface  to  join  the 
first  incision. 

Amputation  of  the  entire  thumb  with  its  metacarpal 
bone  is  effected  by  making  an  oval  flap  from  the  palmar 


AMPUTATIONS  AT  THE   WRIST.  495 

surface ;  in  the  case  of  the  left  thumb,  the  joint  may  be 
opened  by  an  oblique  incision  on  the  dorsal  surface  of  the 
hand,  beginning  a  little  in  front  of  the  joint  and  being 
carried  down  to  the  web  between  the  thumb  and  fore- 
finger ;  the  palmar  flap  is  then  made  by  thrusting  the  knife 
upward  to  its  point  of  entrance  and  cutting  downward 
and  outward.  In  amputating  the  right  thumb  with  its 
metacarpal  bone,  it  is  better  to  make  the  palmar  flap  first 
by  transfixion,  the  dorsal  flap  being  made  subsequently. 

Fig.  394. 


Incision  for  removal  of  the  fifth  metacarpal  bone.    (Smith.) 


Amputation  of  the  hand  at  the  earpo-metacaqxd  joint  is 
occasionally  performed,  or  between  the  rows  of  carpal 
bones ;  but  is  not,  as  a  rule,  to  be  recommended,  as  the 
carpal  bones  are  apt  subsequently  to  become  diseased  and 
require  removal ;  it  is,  therefore,  better  to  amputate  at  the 
radio-carpal  joint. 

AMPUTATIONS  AT  THE  WRIST. 

Circular  Method.— The  skin  of  the  forearm  near  the 
wrist  being  retracted  bv  an  assistant,  a  circular  incision  of 
the  skin  and  cellular  tissue  is  made  half  an  inch  below  the 
point  of  the  styloid  process  of  the  radius  (Fig.  391,  G). 
The  skin  and  cellular  tissue  are  next  dissected  back  as  far 
as  the  joint,  which  is  opened  and  the  disarticulation  com- 
pleted. 

Antero-posterior  Flap  Method.— This  method  is  also 
employed  in  amputations  at  the  wrist-joint ;  an  incision 
curved  downward  is  made  on  the  back  of  the  hand  from 
one  styloid  process  to  the  other  ;  the  hand  being  flexed, 
the  tendons  are  divided  and  the  joint  opened,  and  the 


496  AMPUTATIONS. 

palmar  flap,  which  should  extend  as  far  as  the  base  of  the 
metacarpal  bones,  is  cut  from  within  outward  (Fig.  395). 
Amputation  at  the  wrist  is  sometimes  performed  by  cut- 
ting a  single  flap  from  the  palm,  the  joint  being  opened 
by  a  transverse  incision  on  the  back  of  the  hand  from  one 
styloid  process  to  the  other. 

Fig.  395. 


Amputation  at  the  wrist.     (Erichsen.) 

Lateral  Flap  Method.— This  method  (Fig.  392,  H)  is 
also  sometimes  employed  in  amputation  at  the  wrist,  and 
may  be  employed  with  advantage  in  cases  of  laceration  of 
the  hand,  in  which  the  injury  to  the  tissues  is  so  great 
as  to  prevent  the  formation  of  the  flaps  used  in  the  other 
methods  of  amputation. 

AMPUTATIONS  OF  THE  FOREARM. 

The  forearm  may  be  amputated  by  the  circular  or  flap 
method,  or  by  making  rectangular  flaps  (Teale's  method). 

Circular  Method. — At  the  lower  portion  of  the  forearm 
the  circular  method  of  amputation  is  to  be  preferred.  A 
circular  incision  of  the  skin  and  cellular  tissue  is  made  and 
a  cuff  is  dissected  up,  the  muscles  and  interosseous  mem- 


AMPUTATIONS  AT  THE  ELBOW. 


497 


brane  being  cut  through  ;  a  three-tailed   retractor  is  next 
applied  and  the  bones  are  divided  with  a  saw. 

Modified  Circular  Method — Amputation  of  the  fore- 
arm by  the  oval  or  mixed  method,  which  consists  in  first 
dissecting  up  two  antero-posterior  oval  flaps  of  skin  and 
cellular  tissue  and  then  dividing  the  muscles  by  a  circular 
incision,  is  also  a  satisfactory  operation  (Fig.  396). 

Fig.  390. 


Amputation  of  the  forearm  by  the  modified  circular  method.    (Bryant.) 

In  amputation  at  the  upper  portion  of  the  forearm, 
antero-posterior  or  lateral  flaps,  cut  from  without  inward 
or  by  transfixion,  or  rectangular  flaps,  may  be  made  with 
advantage. 

AMPUTATIONS  AT  THE  ELBOW. 

The  methods  of  amputation  employed  at  the  elbow  are 
the  anterior  flap,  lateral  flap,  circular,  and  elliptical. 

Anterior  Flap  Method. — A  flap  three  inches  in  length, 
with  its  base  parallel  to  and  half  an  inch  below  the 
condyles  of  the  humerus,  is  cut  either  by  transfixion  or 
from  without  inwTard.  The  joint  is  next  opened  and  the 
lateral  ligaments  divided.  The  olecranon  is  then  ex- 
posed, the  attachment  of  the  triceps  muscle  separated, 
and  a  posterior  flap  cut  from  without  inward,  or  from 
within  outward,  a  little  below  the  line  of  the  condvles 
(Fig.  397,  A). 

Lateral  Flap  Method. — In  amputation  at  the  elbow- 
joint  lateral  flaps  may  be  employed,  cut  either  from  with- 
out inward  or  by  transfixion  (Fig.  397,  B).  A  flap  three 
inches  in  length  is  made  on  the  outer  side  of  the  forearm, 
starting  from  a  point  a  finger's  breadth  below  the  bend 

32 


498 


AMPUTATIONS. 


Fig.  398. 


Fig.  397. 


Circular  amputation  at  the  elbow.   (.Smith.) 
A  Fig.  399. 


Amputation  at  the  elbow-joint.  A.  An- 
terior flap  method.  B.  External  flap 
method.    C.  Circular  method.    (Stimson.) 


Incision  for  elliptical  amputation 
at  the  elbow.     (After  Tkeves.) 


of  the  elbow,  by  transfixion  or  by  cutting  from  with  out 
inward;  a  shorter  internal  flap  is  next  cut  in  the  same 
manner,  and  the  joint  is  opened  and  the  disarticulation 
effected. 

Circular  Method. — An  incision  dividing  the  skin  and 
cellular  tissue  is  made  around  the  limb  three  inches  below 
the  line  of  the  condyles  of  the  humerus  (Fig.  397,  C), 
the  skin   is  dissected   up   and  a  circular  incision  made 


AMPUTATIONS  OF  THE  JAM/.  499 

through   the  muscles,  the  joint  is  opened  and  the  disar- 
ticulation effected  (Fig.  398). 

Elliptical  Method. — En  this  method  of  amputating  at 
the  elbow  an  incision  is  carried  from  the  olecranon  process 
downward  and  forward  to  a  point  a  little  above  the  middle 
of  the  forearm  ;  it  is  then  continued  across  the  anterior 
aspect  of  the  limb,  and  is  carried  back  to  the  olecranon 
process  (Fig.  399).  The  incision  includes  only  the  skin 
and  the  cellular  tissue.  The  flap  having  been  dissected 
up  for  a  short  distance,  the  soft  parts  close  to  the  joint 
are  transfixed  ;  the  muscles  are  cut  obliquely,  so  that  an 
anterior  flap  is  formed.  This  flap  is  held  up,  the  bones 
are  disarticulated,  the  attachment  of  the  triceps  tendon  to 
the  olecranon  is  divided,  and  any  tissues  which  have 
escaped  division  along  the  posterior  aspect  of  the  limb 
are  severed.  After  the  vessels  have  been  secured,  the  flap 
is  turned  over  and  sutured,  and  a  curved  cicatrix  on  the 
posterior  aspect  of  the  limb  results. 


AMPUTATIONS  OF  THE  ARM. 

The  arm  may  be  removed  at  any  point  below  the  attach- 
ment of  the  muscles  at  the  axilla,  by  either  the  circular, 
flap,  oval,  or  modified  circular  method. 

Circular  Method. — This  amputation  is  usually  em- 
ployed in  removing  the  arm  in  its  lower  third.  A  circu- 
lar incision  of  the  skin  and  subcutaneous  tissue  is  first 
made,  and  when  the  cuff  has  been  dissected  up  a  circular 
division  of  the  muscles  is  made ;  after  applying  the  re- 
tractor the  bone  is  sawed  through  (Fig.  400).  * 

Transfixion  Method.— From  the  central  position  of  the 
bone  in  the  arm  the  flap  method  in  amputating  the  arm  is 
preferred  by  many  operators.  The  arm  being  grasped  bv 
the  hand,  the  point  of  a  medium-sized  amputating-knife  is 
thrust  through  the  arm  so  as  to  pass  over  the  humerus  and 
make  its  exit  at  a  corresponding  point  in  the  skin  on  the 
opposite  side ;  a  flap  of  sufficient  length  is  cut  from  within 
outward.    The  knife  is  next  passed  behind  the  bone  and  a 


500 


AMPUTATIONS. 


posterior  flap  is  cut  in  the  same  manner  (Fig.  401) ;  the 
bone  is  next  cleared  of  muscular  tissue,  the  flaps  are 
retracted,  and  it  is  divided  with  a  saw. 


Fig.  400. 


Circular  amputation  of  the  arm.    (Smith.) 

Lateral  flaps  may  be  made  in  this  amputation  instead 
of  the  antero-posterior  flaps,  and  they  may  be  cut  from 
within  outward  in  the  same  manner. 


Fig.  401. 


Amputation  of  the  arm  by  transfixion.    (Bryant.) 

Modified  Circular  Method. — This  method  of  amputat- 
ing the  arm  is  also  employed  with  advantage.     Two  oval 


AMPUTATIONS  AT  THE  SHOULDEBr-JOINT.      501 

flaps  of  skin  and  cellular  tissue  are  dissected  up,  and   the 
muscles  divided  by  a  circular  sweep  of  the  knife. 

Fig.  4u2. 


Esmareh's  strap  applied  in  high  amputation  of  the  arm.    (Smith.) 

In  high  amputations  of  the  arm  there  is  sometimes  not 
sufficient  room  to  apply  Esmarch's  strap  or  a  tourniquet 
to  the  arm  itself  to  control  the  hemorrhage  during  the 
operation  ;  in  such  cases  the  strap  may  be  passed  from  the 
axilla  around  the  outer  end  of  the  clavicle,  as  is  done  to 
control  the  bleeding  during  amputation  at  the  shoulder- 
joint  (Fig.  402),  or  Wyeth's  pins  may  be  employed. 

AMPUTATIONS  AT  THE  SHOULDER-JOINT. 

Several  methods  of  operation  are  employed  in  ampu- 
tating at  the  shoulder-joint,  such  as  Larrey's  method, 
Lisfranc's  and  Dupuytren's  methods,  and  Spence's  method 
(Fig.  403).  The  control  i  f  the  bleeding  from  the  axillary 
artery  during  the  operation  is  a  matter  of  the  first  impor- 
tance ;  it  may  be  arrested  by  pressure  made  upon  the 
subclavian  artery,  as  it  crosses  the  first  rib.  with  the 
thumb,  or  the  padded  handle  of  a  large  key.  or  by  the 
fingers  of  an  assistant  grasping  the  axillary  flap  and  com- 
pressing the  vessel  after  the  head  of  the  bone  has  beer 


502 


AMPUTATIONS. 


disarticulated,  or  by  the  use  of  an  elastic  strap  applied 
around  the  axilla  and  shoulder  (Fig.  402). 


Fig.  403. 


Amputation  at  the  shoulder-joint.    A.  Oval,  or  Larrey's  method.    B.  Double- 
flap,  or  Dupuytren's  method.     (Stimson.) 

WyetKs  pins  may  also  be  employed  with  an  elastic  tube 
or  strap  to  control    bleeding  during   amputation    at   the 

Fig.  404. 


Method  of  applying  Wyeth's  pins. 


shoulder-joint.     The  anterior  pin  is  passed  through  the 
anterior  fold  of  the  axilla,  and  is  brought  out  in  front  of 


L ABBEY'S  METHOD. 


503 


the  acromion,  the  posterior  pin  is  passed  through  the  pos- 
terior fold  of  the  axilla  and  is  brought  out  behind  the  acro- 
mion, the  rubber  strap  or  tube  is  then  wrapped  around  the 
shoulder  behind  the  pins  and  controls  the  hemorrhage  dur- 
ing the  operation  (Fig.  404). 

Larrey's  Method"— In  this  method  of  amputation  the 
point  of  the  knife  is  entered  just  below  the  acromion 
process,  and  a  deep  incision  three  inches  in  length  is  made 

Fig.  405. 


Amputation  at  the  shoulder-joint  by  Larrey's  method. 

down  to  the  head  of  the  bone  along:  the  axis  of  the  arm  ; 
from  the  middle  of  this  incision  two  others  are  made 
obliquely  downward  to  the  points  where  the  anterior  and 
posterior  folds  of  the  axilla  end  in  the  tissues  of  the  arm  ; 
the  latter  incisions  should  be  only  sufficiently  deep  to  divide 
the  skin  and  superficial  fascia  (Fig.  403,  A).  The  flaps 
are  then  dissected  up  until  the  head  of  the  bone  is  well 
exposed,  and,  after  opening  the  capsule  and  dividing  the 


504 


AMPUTATIONS. 


muscles  inserted  into  the  neck  and  tuberosities  of  the 
humerus,  which  division  may  be  facilitated  by  rotating 
the  head  of  the  bone  outward  and  inward,  the  disarticu- 
lation is  effected  by  adducting  the  elbow ;  the  knife  is 
next  passed  downward  behind  the  bone  and  made  to  cut 
outward  in  the  line  of  the  cutaneous  incisions,  an  assistant 
controlling  the  artery  before  it  is  divided  by  grasping 
the  axillary  tissues  behind  the  knife  with  his  fingers  if 
Wyeth's  pins  have  not  been  employed. 

Dupuytren's  Method. — In  this  method  of  amputation 
at  the  shoulder-joint  the  flaps  may  be  cut  either  by  trans- 
fixion or  from  without  inward ;  the  large  flap  embraces 


Fig.  406. 


Amputation  at  the  shoulder-joint.    Dupuytren's  method.     (Bryant.1) 

the  greater  part  of  the  deltoid  muscle  (Fig.  403,  £),  and 
the  smaller  or  short  flap  is  cut  from  the  inside  of  the  arm 
after  the  head  of  the  bone  has  been  disarticulated.  When 
cut  by  transfixion,  the  point  of  the  knife  should  be  entered 
an  inch  in  front  of  the  acromion  process  and  pushed  across 
the  outer  aspect  of  the  head  of  the  humerus,  and  brought 
out  at  the  posterior  fold  of  the  axilla  ;  the  knife  is  made 
to  cut  downward  until  a  large  deltoid  flap  is  formed. 
This  flap  is  turned  up  and  the  head  of  the  bone  is  dis- 
articulated ;  the  knife  being  placed  behind  it,  a  short  flap 


SPENCE'S  METHOD. 


505 


is  formed,  keeping  close  to  the  bone,  so  that  the  vessels 
are  divided  with  the  last  cut  of  the  knife  (Fig.  406).  An 
assistant  should  control  the  vessel  by  grasping  the  axillary 
tissues  with  his  fingers  behind  the  knife. 

Lisfranc's  Method.— In  this  method  of  amputation  at 
the  shoulder-joint  the  point  of  the  knife  is  entered  at  the 
outer  side  of  the  coracoid  process,  and  is  carried  across  the 
outer  aspect  of  the  head  of  the  humerus  and  brought  out 
a  little  below  the  posterior  border  of  the  acromion  process, 
and  a  long  flap  is  cut  downward.  This  flap  is  turned  up 
and  the  attachments  of  the  head  of  the  bone  are  divided 
and  it  is  disarticulated.  The  knife  is  again  entered  behind 
the  bone,  and  a  long  posterior  flap  cut  from  within  outward. 

Spence's  Method.— In  this  method  of  amputation  at 
the  shoulder-joint  an  incision  is  made  down  to  the  head  of 


Fig.  407. 


Amputation  at  the  shoulder-joint.    Spence's  method.    (Stimson.) 

the  humerus  immediately  in  front  of  the  coracoid  process, 
and  is  continued  downward  through  the  clavicular  fibres 
of  the  deltoid  and  the  pectoralis  major  muscles  until  the 
attachment  of  the  latter  to  the  humerus  is  reached  (Fig. 
407).     The  incision  is  now  carried  backward  to  the  pos- 


506  AMP  VTA  TIONS. 

terior  fold  of  the  axilla.  A  second  incision,  including  only 
the  skin  and  cellular  tissue,  is  next  made  from  the  anterior 
portion  of  the  first  incision  across  the  inside  of  the  arm  to 
meet  the  incision  on  the  outer  part.  The  outer  flap  thus 
formed  is  turned  up  and  the  head  of  the  bone  is  disarticu- 
lated. The  operation  is  completed  by  dividing  the  remain- 
ing tissues  on  the  axillary  aspect. 

Amputation  above  the  Shoulder -joint. — This  form 
of  amputation  consists  in  removal  of  the  arm  with  a  part 
or  the  whole  of  the  scapula,  and  a  portion  or  whole  of  the 
clavicle. 

As  this  form  of  amputation  is  required  in  cases  in  which 
the  laceration  of  the  parts  has  extended  beyond  the  shoul- 
der-joint, or  in  cases  of  growths  involving  the  tissues  be- 
yond the  joint,  no  definite  rule  can  be  laid  down  for  the  in- 
cisions ;  the  only  rule  being  as  far  as  possible  to  make  them 
in  such  a  manner  that  the  smallest  amount  of  skin  is  sacri- 
ficed, so  that  a  sufficient  covering  for  the  wound  may  be 
obtained.  Treves  recommends  the  following  method:  The 
patient  should  be  placed  on  his  back  close  to  the  edge  of 
the  operating- table.  An  incision  should  be  made  over  the 
clavicle,  extending  from  the  inner  extremity  outward  to  a 
point  a  little  beyond  the  acromioclavicular  articulation, 
which  should  be  carried  down  to  the  bone ;  the  clavicle 
being  exposed,  it  should  be  divided  in  its  middle  third  or 
disarticulated  from  the  sternum,  and,  its  outer  portion 
being  lifted  up,  it  is  disarticulated  at  its  acromial  ex- 
tremity. The  subclavian  vessels  are  thus  exposed,  and 
should  be  tied  by  two  ligatures,  about  an  inch  apart,  and 
the  vessels  finally  divided  between  the  ligatures.  The 
axillary  plexus  of  nerves  should  next  be  divided.  The 
second  incision  is  made  at  the  centre  of  the  first  incis- 
ion, and  the  knife  is  carried  directly  across  the  anterior 
part  of  the  axilla  and  inner  border  of  the  arm  to  the 
inferior  angle  of  the  scapula  ;  from  the  outer  extremity  of 
the  first  incision  over  the  clavicle  a  third  incision  should 
be  made  posteriorly,  across  the  dorsum  of  the  scapula  to 
its  inferior  angle,  joining  the  termination  of  the  second 
incision  (Fig.  408).    Upon  turning  back  the  posterior  flap 


AMPUTATIONS  OF  THE  FOOT. 


507 


thus  formed  and  severing  the  connections  of  the  scapula 
with  the  trunk  and  the  muscular  attachments  which  re- 
main anteriorly,  the  upper  extremity  will  be  entirely  freed 


Fig.  408. 


Amputation  of  arm,  scapula,  and  clavicle,  the  dotted  line  representing  the 
posterior  incision.    (Treves.) 

from  the  trunk.  The  wound,  when  closed,  forms  an 
oblique  line  running  from  above  downward,  outward,  and 
backward. 

AMPUTATIONS  OF  THE  FOOT. 

Amputations  of  the  Toes.— The  phalanges  of  the  toes 
mav  be  removed  in  the  same  manner  as  those  of  the  fin- 
gers. It  is  better  to  amputate  at  the  metatarsophalangeal 
articulations  than  to  attempt  to  remove  them  at  the  joints 
in  front  of  this  articulation,  except  in  the  case  of  the  great 
toe,  as  the  preservation  of  a  portion  of  a  toe  is  rather  a 
discomfort  than  an  advantage,  except  in  the  instance  men- 
tioned. All  incisions  should  be  made  so  that  the  resulting 
cicatrix  does  not  occupv  the  plantar  surface,  and  it  is  well 
to  remember  that  the  web  of  the  toes  is  considerably  below 
the  position  of  the  metatarso-phalangeal  joint. 


508 


AMPUTATIONS. 


The  toes  are  usually  removed  by  an  incision  on  the 
dorsal  surface  a  little  above  the  joint,  which  is  carried 
down  to  the  bone  for  about  an  inch  and  then  diverges  into 
the  web,  and  is  carried  under  the  toe  and  back  on  the 
other  side  to  the  point  of  divergence  (Figs.  409,  410). 


Fig.  409. 


Fig.  410. 


Amputation  of  the  toes  by  the 
racket-shaped  incision  and  flap 
method.    (After  Rotter.) 


Incisions  for  amputation  of  toes  and 
metatarsal  bones.     (Stimson.) 


Amputation  of  Two  Adjoining  Toes. — The  dorsal  incision 
should  be  made  in  the  inter-metatarsal  space  just  above 
the  level  of  the  joint  (Fig.  410,  B)  and  carried  down  to 
the  beginning  of  the  web ;  then  over  the  toes  to  the  be- 
ginning of  the  adjoining  web;  then  under  the  plantar 
surface  of  both  toes  in  the  line  of  the  digito-plantar  fold, 
through  the  web,  and  back  to  the  point  of  divergence. 


AMPUTATIONS  OF  THE  FOOT. 


509 


Amputation  of  the  Great  Toe. — This  may  be  accomplished 
by  means  of  the  racket-shaped  incision  employed  in  am- 
putation of  the  other  toes  (Fig".  109),  or  by  means  of  a 
lateral  flap.  In  the  latter  case  the  knife  is  made  to  enter 
the  joint  by  cutting  through  the  commissure,  and  the 
operation  is  completed  by  carrying  the  knife  through  the 
joint  and  along  the  outer  side  of  the  bone,  forming  a  flap 
of  the  required  size.  In  this  amputation  a  short  dorsal 
flap  and  a  long  plantar  flap  may  be  employed,  or  a  large 
internal  flap  may  be  used. 

Amputation  of  the  Great  Toe  with  its  Metatarsal  Bone. — 
The  incision  begins  upon  the  dorsal  surface  of  the  meta- 
tarsal bone,  a  little  below  the  point  at  which  the  bone  is  to 

Fig.  411. 


Amputation  of  the  great  toe  and  first  metatarsal  bone.    (Smith.) 

be  divided,  and  is  carried  down  below  the  metatarso- 
phalangeal joint,  then  diverges  and  passes  under  the  toe, 
and  comes  back  again  to  the  point  of  divergence  (Fig, 
410,  C).  The  bone  is  exposed  and  cut  through  with  cut- 
ting forceps,  and  is  then  lifted  up  and  dissected  loose  from 
the  tissues  (Fig.  411). 

.  Amputation  of  All  the  Toes. — To  amputate  all  the  toes, 
make  a  dorsal  incision  from  the  head  of  the  fifth  to  the 
head  of  the  first  metatarsal  bone  ;  the  incision  should  be 


510  A  MP  VTA  TIONS. 

a  curved  one  passing  just  in  front  of  the  joints  (Fig.  412). 

Dissect  up  the  flap  and  open  the  joints,  dividing  the  lateral 
ligaments,  and  pass  the  knife  behind 
the  phalanges  and  cut  a  flap  from  the 
plantar  surface. 

Amputations  of  the  Metatarsal 
Bones. — It  is  better  in  these  amputa- 
tions to  leave  the  tarsal  head  of  the 
metatarsal  bone  in  place  and  divide  the 
bone,  or,  in  other  words,  to  do  an  am- 
putation in  continuity  to  prevent  open- 
ing up  the  tarsal  articulations. 

Amputation  of  the  Little  Toe  and  the 
Fifth    Metatarsal    Bone. — The    incision 

incision  for  amputation  for  the  removal  of  the  little  toe  and  the 

of  all  the  toes.  (Smith.)  .  .  .  , 

tilth  metatarsal  bone  is  made  over  the 
bone  a  little  below  the  metatarso-tarsal  articulation,  and  is 
carried  down  and  curved  around  the  toe  (Fig.  410,  D), 
and  after  the  bone  is  exposed  by  dissecting  back  the  flaps 
it  is  divided,  or  the  joint  is  opened  and  it  is  dissected  out. 

Amputation  through  all  the  Metatarsal  Bones. — In  per- 
forming this  amputation  an  incision  is  made  across  the 
dorsum  of  the  foot,  and  a  short  dorsal  flap  is  dissected  up ; 
the  metatarsal  bones  are  next  divided  with  a  saw  and  a 
long  plantar  flap  is  cut  from  within  outward  by  entering 
the  knife  behind  the  ends  of  the  bones. 

Tarso-metatarsal  Amputations. — In  all  amputations 
of  the  foot  involving  the  tarsus  the  surgeon  should  be 
thoroughly  familiar  with  the  anatomy  of  the  foot  and  the 
surgical  landmarks  of  the  different  articulations.  I  shall 
refer  to  those  laid  down  by  Mr.  Bryant,  which  are  as 
follows  : 

"  On  the  inner  side  of  the  foot,  not  far  from  the  inner 
malleolus,  the  tubercle  of  the  scaphoid  (Fig.  413,  A)  is  to 
be  felt  as  a  marked  prominence  ;  about  one-half  an  inch 
in  front  of  this  will  be  found  the  articulation  with  the 
cuneiform  bone  (B),  and  one  inch  in  front  of  this  the  joint 
which  the  surgeon  will  have  to  open  in  Lisfranc's  or  Hey\s 
operation  (C) ;  just  above  the  tubercle  of  the  scaphoid  will 


iMlsn- METATARSAL  AMPUTATIONS. 


511 


be  found  the  articulation  with  the  astragalus,  the  line  of 
Chopart's  amputation  (D).  On  the  outer  side  of  the  foot, 
one  inch  below  the  external  malleolus,  a  sharply  denned 
projection  will  always  be  felt,  which  is  the  peroneal 
tubercle  (E)\  one-half   an  inch  in  front  of    this  will   be 


Fig.  413. 


Surgical  guides  to  the  foot  as  expressed 
by  anatomy.     (Bryant.) 


Fig.  414. 


Incisions  for— A.  Lisfranc's  am- 
putation. B.  Chopart's  amputa- 
tion.   (Stimson.) 


found  the  joint  which  separates  the  os  caleis  from  the 
cuboid  (F),  this  joint  forming  the  outer  circle  to  Chopart's 
amputation.  Half  an  inch  in  front  again,  or  one  inch 
from  the  tubercle,  the  prominence  of  the  fifth  metatarsal 
bone  is  always  to  be  felt  (H),  the  line  above  this  promi- 
nence indicating  the  articulation  with  the   cuboid  bone, 


512 


AMPUTATIONS. 


which  forms  the  outer  boundary  of  the  incision  for  Hey?s 
or  Lisfranc's  operation." 

Tarso-metatarsal  Amputation  (Lisfranc's). — The  in- 
cision for  this  amputation  is  a  curved  one  carried  across 
the  dorsum  of  the  foot  from  the  base  of  the  fifth  to  the 
base  of  the  first  metatarsal  bone  (Fig.  414,  A).  The  in- 
cision should  involve  the  skin  only,  its  centre  lying  half 
an  inch  or  more  below  the  centre  of  the  line  of  the  articu- 
lations, and  it  should  begin  and  end  at  the  sides  of  the 
foot  at  their  junction  with  the  sole.    A  plantar  flap  should 

Fig.  415. 


Amputation  at  the  tarso-metatarsal  joint.     (Lisfranc's.) 


be  marked  out  by  a  curved  incision  crossing  the  sole  of 
the  foot  near  the  origin  of  the  toes,  starting  and  ending  at 
the  same  points  as  the  dorsal  incision. 

The  dorsal  flap  is  next  dissected  back  to  the  line  of  the 
articulations ;  the  tendons,  muscular  fibres,  and  fascia 
being  divided,  the  joints  between  the  tarsal  and  metatarsal 
bones  are  opened  with  a  stout,  narrow-bladed  knife  (Fig. 
415).  Difficulty  is  sometimes  experienced  in  opening  the 
joint  between  the  head  of  the  second  metatarsal  bone  and 
the  second  cuneiform  bone,  which  occupies  a  position  higher 


MEDIO-  TA  BSAL  A  MP  UTA  TION. 


513 


on  the  foot  than  the  other  articulations.  The  disarticu- 
lation may  also  be  facilitated  by  forcibly  depressing  the 
anterior  portion  of  the  foot.  After  all  the  joints  have 
been  opened,  the  knife  is  passed  behind  the  ends  of  the 
metatarsal  bones,  and  a  plantar  flap  is  cut  from  within 
outward,  following  the  line  of  the  incision  previously 
marked  out.  The  plantar  flap  may  be  cut  from  without 
inward  if  preferred. 

Tarso-metatarsal  Amputation  (Hey's). — The  line  of 
incision  and  the  steps  of  this  operation  are  similar  to  those 
in  Lisfranc's  amputation,  with  the  exception  that  Hey 
sawed  off  the  projecting  portion  of  the  internal  cuneiform 
bone  after  disarticulating  the  metatarsal  bones.  This 
modification,  although  it  improves  the  appearance  of  the 
stump,  possesses   no  advantages  over  the  latter  procedure. 

Medio -tarsal  Amputation  (Chopart's). — In  this  ampu- 
tation the  disarticulation  is  through  the  joints  formed  by 

Fig.  416. 


Lines  of  incision  for— A.  Chopart's  amputation.  B.  Syme's  amputation. 
D.  Section  of  bone  in  Syme's  amputation.  C.  Subastragaloid  amputation. 
(Stimson.) 

the  astragalus  and  calcaneum  behind  and  the  scaphoid  and 
cuboid  in  front.  An  incision  is  made  from  the  tubercle 
of  the  scaphoid  across  the  dorsum  of  the  foot  an  inch  in 
front  of  the  head  of  the  astragalus  to  the  lower  and  outer 

33 


514 


AMPUTATIONS. 


border  of  the  cuboid  (Fig.  41 4,  B).  The  plantar  flap  is 
next  marked  out  by  an  incision  beginning  and  ending  at 
the  same  points  as  the  first  incision  and  crossing  the  sole 
of  the  fout  four  or  five  finger-breadths  nearer  the  toes 
(Fig.  416,  A).  The  dorsal  flap  is  next  dissected  up,  and 
after  the  tendons  and  fascia  have  been  divided  the  joint 
is  opened  and  a  plantar  flap  is  cut  from  within  outward, 
following  the  line  of  the  previously  marked-out  plantar 
incision  (Fig.  417). 

Fig.   417. 


Chopart's  amputation.    (Bryant.) 

Subastragaloid  Amputation. — In  this  amputation  all 
the  bones  of  the  foot  are  removed  except  the  astragalus. 
An  incision  is  made,  beginning  an  inch  below. the  tip  of 
the  external  malleolus,  which  is  carried  forward  to  the 
base  of  the  fifth  metatarsal  bone  ;  it  is  then  carried  over 
the  dorsum  of  the  foot  to  the  calcaneo-cuboid  articulation 
(Fig.  415,  C).  The  joints  between  the  scaphoid  and 
astragalus  and  between  the  astragalus  and  os  calcis  are 
opened,  and  the  latter  bone  is  carefully  dissected  out ; 
the  ligaments  are  divided  and  the  astragalus  only  is 
allowed   to   remain    in    place. 


AMPUTATIONS  AT  THE  ANKLE-JOINT. 

Syme's  Amputation  at  the  Ankle-joint. —  In  this 
amputation,  the  foot  being  at  a  right  angle  to  the  leg,  an 
incision  is  made  from  the  centre  of  one  malleolus  directly 


AMPUTATIONS  AT  THE  ANKLE-JOINT 


515 


across  the  sole  of  the  foot  to  the  centre  of  the  opposite 
malleolus  (Fig.  416,  B).  The  tissues  of  the  heel  are 
next  carefully  dissected  from  the  bone  by  keeping  the 
knife  close  to  the  osseous  surface  until  the  tuberosity  of 
the  os  calcis  is  fairly  turned  (Fig.  41 8).  The  two  extremi- 
ties of  the  first  incision  are  then  joined  by  a  transverse 
one  across  the  instep,  and,   the  joint    being  opened,  the 

Fig.  418. 


Syme's  amputation  at  the  ankle-joint.    (Skey.) 

lateral  ligaments  are  divided  to  complete  the  disarticula- 
tion. The  knife  is  next  used  to  clear  the  malleoli,  and 
they  are  next  removed  by  the  saw  in  the  line  indicated 
(Fig.  416,  D). 

Pirogoff  's  Amputation  at  the  Ankle-joint. — In  this 
amputation  the  posterior  portion  of  the  os  calcis  is  re- 
tained. The  incision  is  carried  from  the  tip  of  the  inner 
malleolus,  over  the  instep,  half  an  inch  in  front  of  the 
anterior  edge  of  the  tibia,  to  a  point  half  an  inch  in  front 
of  the  tip  of  the  outer  malleolus  ;  a  second  incision,  cross- 


516 


AMPUTATIONS. 


ing  the  sole  of  the  foot  and  carried  down  to  the  bone,  is 
next  made  (Fig.  419,  A).     The  plantar  flap  is  dissected 


Fig.  419. 


Pirogoff's  amputation.    A.  Cutaneous  incision.    B.  Line  of  section  of  bones. 

(Stimson.) 

Fig.  420. 


Application  of  saw  to  os  calcis  in  Pirogoff's  amputation.    (Erichsen.) 


back  for  a  quarter  of  an  inch,  the  joint  is  opened   by 
dividing  the  lateral  ligaments,  the  astragalus  is  disarticu- 


AMPUTATIONS  AT  THE  ANKLE-JOINT 


517 


lated,  and  the  malleoli  are  exposed.  A  narrow  saw  is  next 
applied  to  the  upper  and  posterior  part  of  the  ealeaneum 
behind  the  astragalus,  and  the  former  is  divided  obliquely 
downward  in  the  Hue  of  the  plantar  incision  (Fig.  420). 
The  malleoli  and  a  thin  slice  of  the  tibia  are  next  removed 
with  the  saw,  as  in  Syme's  amputation  (Fig.  419,  B). 
Some  surgeons  do  not  remove  the  malleoli,  but  press  the 
sawed  surface  of  the  os  calcis  between  them  when  it  is 
possible  to  do  so.  The  position  of  the  os  calcis  in  relation 
to  the  tibia  after  union  has  occurred  is  shown  in  Fig.  421. 


Fig.  421. 


Union  between  ealeaneum  and  tibia  in  Pirogoff 's  amputation.    (Hewson.) 

Roux's  Amputation  at  the  Ankle-joint. — In  this 
method  of  amputation  an  incision  is  made  at  the  outer 
edge  of  the  tendo-Achillis,  a  little  above  its  insertion, 
which  is  carried  forward  under  the  outer  malleolus,  and 
across  the  instep  half  an  inch  in  front  of  the  anterior 
edge  of  the  tibia,  and  back  to  a  point  just  in  front  of 
the  inner  malleolus ;  the  incision  is  carried  from  this 
point  downward  and  partly  across  the  sole  of  the  foot, 
and  then  back  to  the  point  of  origin  of  the  original  in- 
cision (Fig.  422).     The  flaps,  are  dissected  up  for  a  short 


518 


AMPUTATIONS. 


distance,  the  ankle-joint  is  opened,  disarticulation  is  effected, 
and  the  internal  flap  is  carefully  dissected  from  the  bones. 

Other  methods  of  amputation  of  the  foot  are  sometimes 
employed,  such,  for  instance,  as  that  advocated  by  Han- 
cock, who  has  combined  Pirogoff's  amputation  with  the 
subastragaloid  method,  bringing  the  sawed  surface  of  the 
os  calcis  in  contact  with  a  transverse  section  of  the  astrag- 
alus. 

Hancock  has  advocated  the  propriety  of  amputating 
the  foot  without  regard  to  the  position  of  the  tarsal  joints, 

Fig.  422. 


Incision  in  Roux's  amputation. 


cutting  the  flaps  of  sufficient  length  and  dividing  the  bones 
with  a  saw. 

Tripier  has  also  modified  the  subastragaloid  amputation 
by  leaving  the  upper  part  of  the  calcaneum,  which  he 
saws  through  on  a  level  with  the  sustentaculum  tali,  and 
at  right  angles  to  the  axis  of  the  leg  ;  the  external  incisions 
are  made  as  in  Chopart's  amputation. 

In  the  method  advocated  by  Mikulicz  the  astragalus  and 
calcaneum  are  removed,  the  ends  of  the  tibia  and  fibula 
are  sawed  off,  and  the  sawed  surfaces  of  the  scaphoid  and 
cuboid  are  approximated  to  these,  the  stump  resulting 
resembling  the  foot  of  pes  equinus. 


AMPUTATIONS  OF  THE  LEG.  519 

AMPUTATIONS  OF  THE  LEG. 

The  leg  may  be  amputated  at  its  lower,  middle,  or  upper 
third,  the  rule  being  to  save  as  much  of  the  limb  as  pos- 
sible ;  but  as  regards  the  application  of  prosthetic  appa- 
ratus, I  think  the  stumps  resulting  from  amputations  in 
the  middle  and  upper  thirds  will  be  found  more  satisfac- 
tory. It  is  well  also  in  sawing  the  bones  to  divide  the 
fibula  at  a  slightly  higher  point  than  the  tibia.  The 
circular,  modified  circular,  oval,  elliptical,  long  anterior 
flap,  rectangular  flap,  antero-posterior  flap,  lateral  flap,  or 
external  flap  method  may  be  employed. 

Circular  Method. — A  circular  incision  is  made  through 
the  skin  and  connective  tissue  just  above  the  malleoli,  the 
cuff  is  dissected  up  for  a  sufficient  distance,  a  circular 
incision  of  the  tendons  and  muscles  is  next  made,  and  the 
tissues  being  retracted,  the  bones  are  divided  with  a  saw. 

Modified  Circular  Method. — In  this  method  of  ampu- 
tation of  the  \eg  two  oval  flaps,  either  antero-posterior  or 
lateral,  of  the  skin  and  connective  tissue  are  marked  out 
by  incisions.  The  flaps  are  then  dissected  up  to  the  ends 
of  the  incisions,  and  a  circular  division  of  the  muscles  is 
made  ;  Fig.  423,  A  ). 

Elliptical  Method. — In  this  method  of  amputation  the 
incision  is  in  the  form  of  an  ellipse  ;  its  lower  end  crosses 
the  heel  below  the  insertion  of  the  tendo-A  chillis,  and  the 
upper  end  of  the  incision  is  about  an  inch  above  the  ante- 
rior articular  edge  of  the  tibia  (Fig.  424.  B). 

Long  Anterior  Flap  Method. — An  anterior  flap  equal 
in  length  to  the  diameter  of  the  leg  at  its  base  is  marked 
out  by  a  curved  incision  through  the  skin  beginning  at 
the  posterior  edge  of  the  tibia  on  the  inner  side,  a  little 
below  the  point  at  which  the  bones  are  to  be  divided,  and 
is  carried  over  the  leg  to  a  point  directly  opposite  over  the 
fibula  (Fig.  424,  A).  The  anterior  muscles  are  divided 
transversely  half  an  inch  above  the  lower  end  of  the  flap, 
and  are  dissected  from  the  bone  to  the  base  of  the  flap. 
The  posterior  flap  is  then  made  by  entering  the  knife 
behind  the  bones  at  the  point  of  the  original  incision  and 
cutting  directly  outward. 


►20 


AMPUTATIONS. 


Fig.  423. 


Fig.  424. 


Fig.  423.— Amputation  of  the  leg.  A.  Modified  circular  method.  B.  Rec- 
tangular flap.  C.  Antero-posterior  flap.  The  dotted  lines  indicate  the  levels 
at  which  the  bones  are  to  be  sawn  through.     (Stimson.) 

Fig.  424.— Amputation  of  the  leg.  A.  Long  anterior  flap.  B.  Elliptical  flap. 
C.  At  upper  third.    (Stimson.) 

Rectangular  Flap  Method  (Teale). — In  this  method 
of  amputation  of  the  leg  an  incision  equal  in  length  to 
half  of  the  circumference  of  the  leg  is  made  from  the 
point  at  which  the  bones  are  to  be  divided  on  one  side 


AMPUTATIONS  OF  THE  LEG.  521 

Fig.  425. 


Modified  circular  amputation  of  the  leg.    (Bryant.) 

of  the  leg,  and  is  carried  across  the  limb  and  back  upon 
the  opposite  side  to  a  point  opposite  the  point  of  starting. 
The  flap  thus  marked  out  is  dissected  up  to  its  base,  and 
a  posterior  flap  of  one-fourth  the  length  is  next  cut  by  a 
transverse  incision  down  to  the  bones,  and  is  dissected  back 
to  the  line  of  the  origin  of  the  first  incision  (Fig.  423,  B). 
The  long  flap  is  next  doubled  back  and  its  edges  secured 
to  the  posterior  flap,  or  the  long  flap  may  be  cut  from 
the  posterior  surface  of  the  leg  and  the  short  flap  from 
the  anterior  surface. 

Antero-posterior  Flap  Method. — A  long  anterior  flap, 
including  half  of  the  circumference  of  the  limb,  may  be 
cut  from  without  inward,  composed  of  skin,  connective 
tissue,  and  muscles ;  and  a  short  posterior  flap,  cut  from 
within  outward,  may  also  be  employed.  This  method  is 
often  employed  in  amputations  in  the  upper  portion  of  the 
leg  (Fig.  423,  C). 

Lateral  Flap  Method. — In  the  lower  and  middle  thirds 
of  the  leg  the  method  of  amputation  by  means  of  lateral 
skin  flaps  may  be  employed  with  advantage.  In  this 
method  an  incision  is  made  over  the  spine  of  the  tibia, 
and  an  oval  flap,  embracing  one-half  of  the  circumference 
of  the  leg,  composed  of  the  skin  and  connective  tissue,  is 
dissectedup  ;  starting  from  the  same  point,  a  similar  flap 
is  formed  on  the  opposite  side  of  the  leg  and  dissected  up ; 
the  muscles  at  the  upper  extremity  of  the  flaps  are  next 
divided  by  a  circular  incision  and  the  bones  are  divided 
with  a  saw. 

External  Flap  Method  (Sedillot). — In  this  method  of 


522  AMPUTATIONS. 

amputation  of  the  leg  the  point  of  the  knife  is  entered  a 
finger's  breadth  external  to  the  spine  of  the  tibia  and 
carried  outward,  grazing  the  fibula,  and  is  brought  out  as 
far  as  possible  to  the  inner  side  ;  a  flap  three  or  four  inches 
in  length  is  then  cut  from  within  outward ;  the  extremities 
of  the  incision  are  next  united  by  an  incision  across  the 
inner  side  of  the  limb,  involving  the  skin  only  ;  any  re- 
maining muscular  tissue  is  next  divided  and  the  bones  are 
sawed.  The  long  external  flap  is  then  brought  over  the 
ends  of  the  bones  and  fastened  to  the  edges  of  the  incision 
on  the  inner  side  of  the  limb.  Professor  Ashhurst  modified 
this  operation  by  cutting  the  long  external  flap  from  with- 
out inward,  and  made  also  a  short  internal  flap  in  the 
same  manner.  By  either  method  the  resulting  stump  is  a 
good  one,  with  the  ends  of  the  bones  covered  by  the  tissues 
of  the  external  flap. 

AMPUTATIONS  AT  THE  KNEE-JOINT. 

Amputations  at  the  knee-joint  may  be  done  either  by 
the  circular  or  elliptical  incision,  or  by  means  of  flaps, 
and  may  consist  in  simple  disarticulations  or  sections 
through    the    condyles  of  the    femur. 

Elliptical  Method. — In  this  operation  an  incision 
crossing  the  spine  of  the  tibia,  five  finger-breadths  below 
the  lower  extremity  of  the  patella,  is  carried  around  the 
back  of  the  leg  three  finger-breadths  higher  than  in  front ; 
the  tissues  on  the  front  of  the  leg  are  dissected  up  until 
the  tendon  of  the  patella  is  exposed  ;  the  leg  is  then  flexed 
and  the  ligament  of  the  patella  is  divided  ;  the  capsular 
ligament  and  the  lateral  and  crucial  ligaments  are  next 
severed,  care  being  taken  not  to  injure  the  popliteal  ves- 
sels with  the  point  of  the  knife.  The  tibia  is  next  drawn 
forward,  the  knife  is  passed  behind  its  posterior  border,  and 
the  remaining  soft  parts  are  divided  from  within  outwTard. 

Anterior  Flap  Method. — In  this  method  of  amputation 
a  long  cutaneous  flap  is  formed.  The  incision,  beginning 
half  an  inch  below  the  articulation,  is  carried  five  inches 
below  the  patella ;  crossing  the  anterior  surface  of  the  leg, 


AMPUTATIONS  AT  THE  KNEE-JOINT. 


523 


it  is  carried  hack  to  the  condyle  of  the  femur  on  the  oppo- 
site side.  This  flap  is  dissected  up,  and  the  ligament  of 
the  patella  divided  and  the  disarticulation  effected.  A 
short  posterior  flap,  uniting  the  anterior  incision  one 
inch  below  its  extremities,  is  next  cut  by  transfixion  or 
from  without  inward  (Fig.  426,  A).  The  patella  is  not 
removed. 

Fig.  426. 


Amputations  at  the  knee-joint  and  lower  third  of  the  thigh.  A.  Long  anterior 
flap.  B.  Amputation  through  condyles.  B'.  Line  of  section  of  the  condyles  of 
the  femur.     C.  Modified  flap  at  lower  third  of  thigh.     (Stimson.) 


Amputation  through  the  Condyles  of  the  Femur. — 
In  this  amputation,  which   is  known  as  Carden's  ampu- 


524  AMPUTATIONS. 

tation,  an  anterior  flap,  whose  lower  extremity  is  three 
finger-breadths  below  the  patella,  is  cut  and  the  disarticu- 
lation effected ;  the  posterior  soft  parts  are  divided,  the 
patella  removed,  and  the  condyles  next  sawed  through  just 
above  the  edge  of  the  articular  cartilage  (Fig.  426,  B). 
Lateral  Flap  Method. — In  this  operation  an  incision 
is  made  just  below  the  patella,  and  is  carried  down  the 
spine  of  the  tibia  for  three  inches,  and  is  then  carried 
backward  to  the  middle  of  the  leg  at  a  point  opposite  the 
beginning  of  the  incision  ;  a  similar  flap  is  cut  on  the 
opposite  side  of  the  leg,  and  the  flaps  dissected  up  to 
the  line  of  the  articulation.  When  this  point  is  reached, 
the  joint  is  opened  and  the  disarticulation  effected.  The 
patella  is  not  removed  (Fig.  427). 

Fig.  427. 


Amputation  at  the  knee-joint  by  lateral  flaps.    (Smith.) 

Gritti's  Amputation  at  the  Knee-joint. — In  this  opera- 
tion a  long  rectangular  anterior  flap  is  first  cut  and  dis- 
sected up,  and  after  the  disarticulation  has  been  effected 
the  skin  covering  the  posterior  surface  of  the  knee  is  cut 
from  within  outward.  The  condyles  of  the  femur  are 
next  removed  by  a  saw  above  the  edge  of  the  articular 
cartilage,  and  the  articular  surface  of  the  patella  is  removed 
by  the  saw  or  cutting  forceps.  The  patella  is  next  brought 
down,  so  that  its  sawed  surface  is  in  contact  with  the 
sawed  surface  of  the  condyles,  and  the  flaps  are  brought 
together  (Fig.  428,  A). 


AMPUTATIONS  OF  THE  THIGH. 
Fig.  428. 


525 


A.  Gritti's  amputation  at  the  knee.  A'.  Lines  of  division  of  the  bones.  B. 
Amputation  of  the  thigh,  long  anterior  flap.  B'.  Division  of  the  bone.  C.  Am- 
putation at  the  lower  third  of  the  thigh.  C.  Division  of  the  bone.  D.  Disarticu- 
lation at  the  hip-joint.     (Stimson.) 


AMPUTATIONS  OF  THE  THIGH. 

Modified  Circular  Method. — Two  oval  flaps  of  skin 
and  connective  tissue,  the  upper  extremities  of  which  are 
several  inches  above  the  condyles  of  the  femur,  are  marked 
out  by  incisions  and  dissected  up,  the  muscles  are  next 


526  AMPUTATIONS. 

divided  by  a  circular  incision,  and  the  bone  is  divided 
with  a  saw. 

Long  Anterior  Flap  Method. — In  this  operation  an 
incision  is  made  on  the  anterior  aspect  of  the  thigh, 
marking  out  a  flap  whose  length  is  equal  to  one-third, 
and  whose  width  at  its  base  is  equal  to  two-thirds,  of  the 
circumference  of  the  limb.  The  anterior  muscles  are  next 
divided  obliquely  upward  and  backward,  so  that  the  flap 
shall  not  be  too  thick,  and  the  posterior  muscles  are  cut 
transversely  and  the  bone  divided  with  a  saw  (Fig.  428,  B). 

Amputation  in  the  lower  third  of  the  thigh  may  also  be 
effected  by  employing  a  long  anterior  and  a  short  posterior 
flap.  The  anterior  flap  is  cut,  its  lower  extremity  extend- 
ing down  to  the  lower  edge  of  the  patella,  and  after  dis- 
secting up  the  skin  and  cellular  tissue  to  the  upper 
extremity  of  the  patella  the  muscles  are  cut  obliquely  up 
to  the  point  at  which  the  bone  is  to  be  divided.  A  short 
posterior  flap  is  next  cut,  and,  the  soft  parts  being  retracted, 
the  bone  is  sawed  through  (Fig.  428,  C). 

Fig.  429. 


Amputation  of  thigh  by  flaps  cut  by  transfixion. 

Transfixion  Method— In  amputations  of  the  thigh  the 
flaps  may  also  be  cut  by  transfixion,  either  lateral  or 
antero -posterior  flaps  being  employed  (Fig.  429). 


AMPUTATIONS  AT  THE  HIP-JOINT. 


527 


Amputation  of  the  Thigh  through  the  Trochanters. 
— When,  for  any  reason,  it  is  inadvisable  to  amputate  at 
the  hip-joint,  an  amputation  may  be  made  through  the 
trochanters,  a  long  anterior  and  a  short  posterior  flap  being 
employed,  with  circular  division  of  the  muscles. 


AMPUTATIONS  AT  THE  HIP-JOINT. 

In  amputations  at  the  hip-joint,  it  is  important  that 
provision  be  made  for  the  control  of  hemorrhage  during 
the  operation,  and  this  is  accomplished  by  compression  of 
the  femoral  artery  by  the  fingers  of  an  assistant,  or  by  the 

Fig.  430. 


Esmarch's   elastic  strap    applied  to  control  hemorrhage  during  amputation 

at  the  hip-joint. 

preliminary  ligation  of  the  femoral  artery  just  below 
Poupart/s  ligament.  Esmarch's  elastic  strap  may  also 
be  employed  for  the  control  of  bleeding  during  amputa- 
tion at  the  hip-joint,  the  strap  being  applied  in  such  a 
manner  that  it  occupies  the  position  of  the  turns  of  a 
spica-bandage  of  the  groin  (Fig.  430). 

Dieffenbaeh  and  Wyeth,  to  avoid  hemorrhage,  make 
first  a  circular  amputation  in  the  continuity  of  the  thigh, 
and  after  controlling  the  hemorrhage  disarticulate  the 
head  of  the  femur  and  remove  it ;  Jordan  and  Senn  dis- 


528 


AMPUTATIONS. 


articulate  the  head  of  the  bone  first  through  an  external 
incision,  and  control  the  bleeding  before  the  amputation  is 
completed  by  passing  an  elastic  tourniquet  around  the  soft 
parts  above  the  point  where  they  are  to  be  divided. 

The  methods  of  amputation  at  the  hip-joint  are  the 
oval,  antero-posterior  flap  and  lateral  flap,  and  modified 
circular  methods. 

Transfixion  Method. — In  this  method  the  point  of  a 
long  amputating  knife  is  thrust  into  the  tissues  about  two 


Fig.  431. 


Amputation  at  the  hip-joint  by  anteroposterior  flaps.    (Holmes.) 

finger-breadths  below  the  anterior  superior  spinous  process 
of  the  ilium,  and  is  pushed  through  the  tissues,  grazing 
the  hip-joint,  and  brought  out  on  the  opposite  side  of  the 
thigh  close  to  the  junction  of  the  scrotum.  The  knife^  is 
next  carried  downward  close  to  the  bone,  and  an  anterior 
flap  of  sufficient  length  is  cut  from  within  outward.  This 
flap  is  held  up  by  an  assistant  and  the  head  of  the  bone 
disarticulated,  and,  the  knife   being   passed   behind   the 


AMPUTATIONS  AT  THE  HIP-JOINT.  529 

bone,  a  posterior  flap  of  equal  length  is  cut  from  within 
outward  (Fig.  431). 

Guthrie's  method  of  amputation  at  the  hip-joint  consists 
in  cutting  the  flaps  from  without  inward,  a  smaller  knife 
being  used  for  this  purpose  and  the  posterior  flap  being 
cut  first. 

Modified  Circular  Method. — In  this  operation  short 
antero-posterior  flaps  of  skin  and  connective  tissue  are 
cut  and  dissected  up,  the  muscles  are  divided  by  a  circular 
incision  at  the  level  of  the  joint,  and  disarticulation  of  the 
head  of  the  femur  is  next  effected. 

Lateral  Flap  Method. — In  this  operation  two  flaps  are 
cut  from  the  inner  and  outer  side  of  the  thigh  by  trans- 
fixing, or  by  cutting  from  without  inward  and  exposing 
the  joint,  which  is  opened  and  disarticulation  of  the  head 

Fig.  432. 


Amputation  at  the  hip-joint  by  external  and  internal  flaps.    (Bryant.) 

of  the  femur  effected  as  in  the  preceding  methods  (Fig. 
432). 

Wyeth's  Method  of  Controlling  Hemorrhage  in  Amputating 
at  the  Hip-joint. — In  amputating  at  the  hip-joint  by  this 
method  the  hip  to  be  operated  upon  is  brought  well  over 
the  edge  of  the  table  and  the  Esmarch  bandage  applied 
to  the  limb.  Two  stout  steel  pins,  twelve  or  fourteen 
inches  in  length,  are  required  :  the  point  of  one  of  these 
pins  is  passed  through  the  skin  one  and  a  half  inches 
below  and  slightly  to  the  inner  side  of  the  anterior  supe- 
rior  spine   of  the  ilium  and  carried  through  the  tissues 

34 


530 


AMPUTATIONS. 
Fig.  433. 


Pins  inserted  and  tube  applied. 
Fig.  434. 


Limb  amputated  and  bone  sawed.    (Wyeth.) 


AMPUTATIONS  AT  THE  HIP-JOINT.  53] 

about  half-way  between  the  great  trochanter  and  the  spine 
of  the  ilium   external  to  the  neck  of  the  femur,  and  its 
point  is  made  to  emerge  just  behind  the  trochanter;    the 
second  pin   is  made  to  enter  the  skin  an  inch  below  the 
crotch,  internal  t<>  the  saphenous  opening,  and  its  point  is 
made  to  emerge  about  an  inch  and  a  half  in  front  of  the 
tuber  ischii.     The  points  of  the  pins  are  next   protected 
with  corks,  and  a  long  piece  of  rubber  tubing  or  an  Es- 
march    elastic    strap    is  wound  tightly  five  or    six  times 
about  the  limb  above  the  fixation  pins  (Tig.  433).     The 
Esmareh    bandage    should    then   be    removed    and  a  cir- 
cular incision  of  the  skin  and  cellular  tissue  made  five 
inches  below  the  constricting  band  ;  this  cellulo-cutaneous 
cuff  should  next  be  reflected  to  the  level  of  the  trochanter 
minor;  a  circular  division  of  all  the  muscles  should  next 
be  made  at  this  point  and  the  bone  divided  with  a  saw. 
The  large  vessels  should  next  be  secured,  and  after  this 
has  been  done  the  rubber  tube  should   be  removed,  and 
any    vessels    which    bleed    should    then    be    tied.     The 
exposed    end    of  the    femur  is  then  grasped    with    bone 
forceps,  and  an  incision  is  next  made  upon  the  outer  side 
through  the  skin  and  muscles  until  the  neck  and  head  of 
the  bone  are  exposed,  and   the  disarticulation  is   accom- 
plished.     Wveth  now  practises  disarticulation  of  the  head 
of  the  femur  in  this  amputation  without  first  sawing  the 
bone.     The  circular  method  or  antero-posterior  flaps  may 
be  employed  to  expose  the  head  of  the  bone. 


PAET   VII. 

EXCISIONS  OR  RESECTIONS. 


EXCISION  OF  THE  JOINTS. 

This  operation  consists  in  the  partial  or  complete  re- 
moval of  the  articular  surface  of  the  bones  making  up  the 
joint.     The  term  resection  is  sometimes  used  as  synony- 
mous with  excision,  but  it  is  usually  employed  to  indicate 
the  removal  of  a  portion  or  the  whole  of  the  shaft  of  one 
of  the  long  bones.     Excisions  or  resections  of  jpints  and 
bones  may  be  required  on  account  of  injury,  disease,  or 
anchylosis  of  a  joint  in  faulty  position.  In  the  operation  of 
excision  of  the  joint  the  incision  should  be  sufficiently  free 
to  permit  of  an  inspection  of  the  diseased  portions  of  the 
joint,  and  it  is  preferable  to  remove  the  diseased  articular 
surface  of  the  bone  with  a  saw ;  small  areas  of  diseased 
bone  may  be  removed  with  the  curette  or  gouge  forceps. 
In  performing  excisions  of  joints  in  young  subjects  care 
should  be  taken  to  see  that  the  epiphyseal  cartilage  is  not 
encroached   upon,  for  if  this  is  removed  the  subsequent 
growth  of  the  limb  may  be  interfered  with.     The  ^  result 
desired   in   cases   of    excision    of  joints,  in   addition   to 
removal  of  the  diseased  tissue,  varies  somewhat  with  the 
joint  involved ;  for  instance,  in  a  knee-joint  anchylosis  is 
desired ;  in  the  shoulder,  hip,  elbow,  and  wrist,  we  wish 
to  obtain  a  movable  false  joint ;  when  the  latter  condition 
is  desired  after  excision,  care  should  be  exercised  not  to 
divide  muscles  or  tendons,  and  as   far  as  possible  not  to 
interfere   with   their   attachments.     When   anchylosis   is 

533 


534 


EXCISIONS  OR  RESECTIONS. 


desired,  the  division  of  muscles  or  tendons  is  not  a  serious 
consideration  ;  any  injury  to  the  principal  arteries,  veins, 
and  nerves  should  always  be  avoided. 

Fig.  435. 

Heavy  scalpel. 
Fig.  436. 


Butcher's  saw. 
Fig.  437. 


Narrow-bladed  saw. 
Fig.  438. 


Chain-saw. 


The  instruments  required  for  the  excision  of  joints  are 
a  stout  scalpel  (Fig.   435),  probe-pointed  knife,  and  ex- 


INSTRUMENTS  FOR   EXCISIONS. 
Fig.  139. 


535 


Lion-jawed  forceps. 
Fig.  440. 


Retractor. 
Fig.  441. 


Elevator. 
Fig.  442. 


Bone-cutting  pliers. 
Fig.  443. 


Knife-bladed  forceps. 
Fig.  444. 


Periosteotome. 


536  EXCISIONS  OR  RESECTIONS. 

cision  saw  with  reversible  blade  (Fig.  436),  narrow-bladed 
saw  (Fig.  437)  or  chain-saw  (Fig.  438),  strong  lion-jawed 
forceps  (Fig.  439),  retractors  (Fig.  440),  an  elevator  (Fig. 
441),  heavy  bone-cutting  pliers  (Fig.  442),  knife-bladed 
forceps  (Fig.  443),  and  a  periosteotome  (Fig.  444). 

Excision  of  the  Shoulder-joint. — In  excising  this 
joint,  the  arm  is  addncted  and  rotated  inward,  and  a 
straight  incision  is  made  extending  from  the  beak  of  the 
coracoid  process  down  the  arm  in  the  line  of  the  bicipital 
groove ;  this  incision  may  be  supplemented  by  a  short, 
transverse  incision  from  the  upper  edge  of  the  first  inci- 
sion to  the  acromion  process  (Fig.  445).     As  the  incision 

Fig.  445. 


Excision  of  the  shoulder-joint.    A.  Regular  incision.   B.  Supplementary 
incision.    (Stimson.) 

is  deepened  the  fibres  of  the  deltoid  muscle  are  divided 
in  this  line,  and  the  capsule  of  the  joint  is  exposed  and 
divided  along  the  outer  edge  of  the  tendon  of  the  long 
head  of  the  biceps  muscle;  this  tendon  is  held  to  one 
side,  the  capsule  of  the  joint  is  freely  opened,  and  the 
muscles  inserted  into  the  tuberosities  of  the  humerus  are 
divided  with  a  probe-pointed  knife  and  freed  with  an  ele- 
vator ;  the  head  of  the  bone  may  then  be  removed  by  saw- 
ing across  the  surgical  neck  of  the  bone  with  a  narrow 
metacarpal  saw  or  chain-saw,  and  the  sawed  surface  of  the 


EXCISION  OF   THE  ELBOW-JOIST.  537 

humerus  rounded  off  with  bone  forceps.  The  end  of  the 
bone  is  then  replaced  in  the  glenoid  cavity  and  the  wound 
drained  and  closed. 

Resection  of  the  Humerus. — A  portion  of  the  humerus 
may  require  resection  for  injury  or  disease.  The  incision 
should  be  made  upon  the  outer  .-ide  of  the  bone  and  car- 
ried down  in  the  muscular  interspaces  on  a  line  with  the 
shaft,  care  being  taken  to  avoid  injury  of  the  musculo- 
spiral  nerve,  which,  as  it  passes  around  the  posterior  sur- 
face of  the  humerus,  lies  close  to  the  bone  between  the 
humeral  heads  of  the  triceps  muscle  at  a  point  correspond- 
ing to  the  deltoid  insertion  anteriorly — i.  e.,  about  the 
centre  of  the  shaft  of  the  humerus.  This  nerve  should  be 
isolated  and  held  aside,  and  the  bone  exposed.  After 
separating  the  periosteum  as  completely  as  possible,  if  the 
shaft  of  the  bone  is  diseased,  it  should  be  removed  by 
dividing  it  in  the  middle  with  a  saw  or  forceps,  and  remov- 
ing each  fragment  as  far  as  the  upper  and  lower  epiphyses, 
or  the  upper  or  lower  portion  only  may  require  removal. 

Excision  of  the  Elbow-joint. — In  excising  this  joint, 
the  forearm  is  slightly  flexed  and  a  longitudinal  incision 
is  begun  about  two  inches  above  the  olecranon  process  and 
a  little  to  its  inner  side,  and  carried  about  three  or  four 
inches  down  in  the  line  of  the  ulna  (Fig.  446)  :  the  tissues 
are  then  divided  down  to  the  bones,  and  the  ulnar  nerve 
is  dissected  from  its  groove  behind  the  inner  condyle  of 
the  humerus  and  held  aside  by  a  retractor  ;  the  tendon  of 
the  triceps  is  divided,  and  its  attachment  to  the  fascia 
and  perio-teum  over  the  olecranon  process  is  separated 
with  an  elevator  or  periosteotome  and  turned  downward  : 
the  joint  is  next  opened  and  the  lateral  ligaments  divided 
as  the  forearm  is  flexed  upon  the  arm.  The  upper  part 
of  the  ulna  and  the  head  of  the  radius  are  freed  with  a 
probe-pointed  knife  and  removed  with  a  narrow-bladed 
saw,  care  being  taken  in  making  the  section  of  the  radius 
to  divide  its  neck  so  that  the  attachment  of  the  biceps 
muscle  is  not  interfered  with.  The  condyles  of  the  humerus 
are  next  freed  and  removed  with  a  saw.  In  freeing  the 
bones  at  the  anterior  portion  of  the  joint,  great  care  should 


538 


EXCISIONS  OE  RESECTIONS. 


be   used   to   avoid   injury  of  the   brachial  artery  and  vein 
and  the  median  nerve. 

Fig.  446. 


Incision  for  excision  of  the  elbow-joint.     (Stimson.) 

Resection  of  the  Radius  or  Ulna. — The  radius  or 
ulna  may  be  resected,  either  entirely  or  partially,  by  mak- 
ing an  incision  upon  the  back  of  the  forearm  over  the 

Fig.  447. 


Resection  of  the  lower  end  of  the  radius. 

bone  to  be  removed ;  the  bone  being  exposed,  the  perios- 
teum is  separated  with  an  elevator  and  the  bone  divided 


EXCISION  OF   1JII-:    WRIST. 


539 


with  a  saw,  and  cadi  fragment  lifted  and  separated  from 
its  muscular  attachments  up  to  the  point  where  it  is 
desired  to  remove  it  (Fig.  447).  If  the  articular  surface 
of  the  bone  is  to  be  removed,  the  disarticulation  should  he 
made  carefully  with  a  strong  scalpel  or  a  probe-pointed 
knife,  care  being  taken  t<>  avoid  injury  of  the  vessels  and 
nerves  lying  upon  its  palmar  surface. 

Excision  of  the  Wrist. — The  wrist  is  covered  on  its 
posterior  and  lateral  aspects  with  skin,  fascia,  and  tendons; 


Fig.  443. 


Articulations  of  the  wrist- joint.     'Lister. ) 

the  relative  position  of  the  bones  entering  into  the  articu- 
lation may  be  seen  in  the  accompanying  figure  (Fig.  448). 
The  wrist-joint  may  be  excised  by  making  a  dorsal 
incision,  beginning  at  the  middle  of  the  ulnar  border  of 
the  second  metacarpal  bone,  and  carried  upward  about 
four  inches,  crossing  the  ulnar  edge  of  the  tendon  of  the 
extensor  carpi  radialis  brevior.  and  splitting  the  dorsal 
ligaments  of  the  wrist  between  the  tendons  of  the  extensor 
secondi  internodii  and  the  extensor  of  the  forefinger  (Fig. 
449).     The  incision  should  be  carried  down  to  the  bone 


540 


EXCISIONS  OB  RESECTIONS. 


and  the  soft  parts  and  tendons  dissected  loose  with  an 
elevator.  By  flexing  the  hand,  the  first  row  of  the  carpus 
is  made  to  present  in  the  wound,  and  the  scaphoid  is  sepa- 
rated from  the  trapezium  and  removed ;  the  semilunar  and 
cuneiform  should  next  be  removed  ;  the  trapezium  and 
pisiform  should  be  left  if  possible.  In  removing  the 
second  row  of  carpal  bones,  the  knife  should  be  passed 
between  the  trapezium  and  the  trapezoid  and  then  into  the 
carpo-metaearpal  joint,  and  by  cutting  the  ligaments  on 
the  dorsal  side  of  the  ends  of  the  metacarpal  bones  the 

Fig.  449. 


Incision  for  excision  of  the  wrist-joint.    (Stimson.) 

trapezoid,  os  magnum,  and  unciform  may  then  be  removed. 
The  lateral  ligaments  are  next  carefully  divided,  and  the 
articular  ends  of  the  radius  and  ulna  removed  with  a  saw ; 
the  ends  of  the  metacarpal  bones  should  next  be  removed 
with  a  saw  or  bone-forceps. 

Resection  of  a  Metacarpal  Bone. — A  metacarpal  bone 
may  be  resected  by  making  a  longitudinal  incision  on  the 
back  of  the  hand  over  the  bone  to  be  removed.  The  in- 
cision should  extend  from  one  articular  end  to  the  other, 
and  the  extensor  tendon  when  exposed  should  be  held  to 


MET  A  CARPO-PHA  LA  NGEA  L  JOINTS. 


541 


one  side  by  retractors;  the  periosteum  should  next  be 
separated  as  far  as  possible,  and  when  the  bone  has  been 
fully  exposed  it  may  be  removed  by  dividing  it  in  the 

Fig.  450. 


Resection  of  a  metacarpal  bone. 


middle  with  bone-forceps  and  then  disarticulating  each 
fragment ;  or  the  articular  ends  may  be  freed  and  the  bone 
removed  in  one  piece  (Fig.  450). 


Fig.  451. 


Excision  of  a  metacarpophalangeal  joint. 

Excision  of  Metacarpophalangeal  Joints  or  Inter- 
phalangeal  Joints. — The  metacarpophalangeal  joint  is 
exposed  by  a  longitudinal  incision  over  the  dorsal  surface 


542 


EXCISIONS  OB  RESECTIONS. 


of  the  knuckle ;  the  extensor  tendon  being  exposed  and 
held  to  one  side,  the  lateral  ligaments  are  divided.  The 
articular  ends  of  the  bones  are  then  exposed  and  removed 
with  a  metacarpal  saw  or  with  bone-forceps  (Fig.  451). 
In  excising  the  interphalangeal  joints,  the  incision  is 
usually  made  upon  the  side  of  the  joint,  and  when  the 
articular  surfaces  of  the  bone  have  been  exposed  they  are 
removed  with  a  small  saw  or  forceps. 

Excision  of  the  Clavicle. — The  clavicle  is  excised  by 
making  an  incision  over  the  bone  from  one  articulation  to 

Fig.  452. 


Resection  of  the  sternal  end  of  the  clavicle. 


the  other,  which  is  carried  directly  down  to  the  bone ;  the 
periosteum  is  then  separated,  and  the  shaft  of  the  bone  may 
be  divided  at  the  middle  and  each  fragment  raised  and 
disarticulated ;  or  the  bone  may  be  disarticulated  at  one 
extremity,  then  raised  up  and  freed  from  its  adherent 
tissues,  and  disarticulated  at  the  other  extremity.  In 
disarticulating  the  sternal  articulation  of  the  clavicle 
(Fig.  452),  a  probe-pointed  knife  should  be  used,  and 
great  care  should  be  exercised  to  avoid  injury  of  the 
important  vessels  and  nerves  which  lie  in  close  proximity 
to  it. 


EXCISION  OF  THE  SCAPULA.  543 

Resection  of  the  Ribs. — In  this  operation,  the  incision 
should  correspond  in  length  and  direction  with  the  portion 
of  bone  to  be  removed,  and  may  be  crossed  at  each  end  by 
a  short  transverse  incision.  The  tissues  overlying  the  rib 
are  then  dissected  loose,  the  periosteum  is  separated  as  far 
as  possible,  the  rib  is  divided  with  bone-forceps  at  two 
points,  the  fragment  is  grasped  with  forceps  and  the 
attachments  to  the  under  surface  of  the  rib  are  separated 
with  an  elevator.  Care  should  be  taken  to  avoid  opening 
the  pleural  cavity. 

Estlander's  Operation. — This  operation  is  employed  in 
cases  of  empyema,  and  consists  in  resecting  the  portions 
of  several  adjoining  ribs  to  allow  the  chest-wall  to  sink 
inward  and  unite  with  the  pulmonary  pleura.  A  rectan- 
gular or  oval  flap  is  marked  out  by  an  incision,  corre- 
sponding to  the  portion  of  the  ribs  to  be  removed,  includ- 
ing all  of  the  tissues  external  to  the  ribs.  The  flap  is 
dissected  up,  and  portions  of  several  ribs  are  divided  with 
bone-forceps  or  a  saw,  and  removed  with  forceps.  If  the 
costal  pleura  is  very  thick,  to  expose  the  cavity  so  as  to 
permit  of  free  drainage  and  allow  the  chest-wall  to  sink 
in,  it  may  be  cut  away  over  a  part  of  the  area  from  which 
the  ribs  have  been  resected ;  one  to  four  inches  of  three  to 
six  adjoining  ribs  may  be  removed. 

Resection  of  the  Sternum. — This  operation  is  per- 
formed by  making  a  longitudinal  incision  over  the  portion 
of  the  bone  to  be  removed ;  the  periosteum  is  separated, 
and  the  diseased  portion  of  the  sternum  is  then  carefully 
freed  with  an  elevator  and  removed. 

Excision  of  the  Scapula. — To  excise  this  bone,  an 
incision  should  be  made  along  the  whole  length  of  the 
spine  of  the  scapula,  and  from  its  posterior  extremity 
two  other  incisions  should  be  made,  one  running  about  an 
inch  or  two  above,  and  the  other  passing  down  the  poste- 
rior border  of  the  bone  to  its  inferior  angle  (Fig.  453)  ; 
the  flaps  thus  made  are  loosened  by  separating  the  muscles 
attached  to  the  outer  surface  of  the  bone.  The  attach- 
ments of  the  deltoid  and  trapezius  muscles  to  the  acromion 
and  spine  of  the  scapula  are  separated,  and  the  lower  angle 


544 


EXCISIONS  OR  RESECTIONS. 


is  freed  by  detaching  the  teres  major  and  serratus  magnus; 
the  bone  is  then  raised  and  the  snbscapularis  muscle 
detached  from  below  upward.  The  neck  of  the  scapula 
should  be  divided  with  a  chain-saw  or  bone-forceps  ;  the 
acromion  is  next  separated  from  the  clavicle  and  the  scapula 
turned  upward,  the  joint  being  opened  from  below.  The 
coracoid  process  should  be  separated  from  its  muscular 
and  ligamentous  attachments,  or  may  be  divided  with  a 

Fig.  453. 


Incision  for  excision  of  the  scapula.  (Stimson.) 

saw  and  left  in  place.  In  clearing  the  supraspinous  fossa, 
care  should  be  taken  not  to  injure  the  suprascapular  nerve 
in  the  suprascapular  notch ;  it  should  be  raised  with  the 
periosteum  and  its  fibrous  sheath. 

Excision  of  the  Hip. — In  excising  the  hip-joint,  a 
curved  or  angular  incision  is  made  from  a  point  about 
three  inches  below  the  crest  of  the  ilium  and  about  the 
same  distance  behind  the  anterior  superior  spine  of  the 
ilium,  which  should  be  carried  downward  over  the  great 
trochanter  in  the  line  of  the  femur  for  about  five  or  six 


EXCISION  OF  THE  SCAPULA. 


545 


inches  (Fig.  454) ;  the  soft  parts  are  dissected  from  the 
great  trochanter  and  upper  part  of  the  shaft  of  the  femur, 
and  the  capsule  of  the  joint  opened.  While  an  assistant 
rotates  the  thigh  inward  and  outward,  the  muscles  attached 
to  the  trochanters  are  shaved  off  close  to  the  bone ;  the 
neck  of  the  femur  is  next  freed  by  the  use  of  a  knife  and 
elevator ;  the  thigh  is  adducted  and  pushed  upward,  and 
the  head  and  neck  of  the  bone  are  made  to  project  from 

Fig.  454. 


Incisions  for  excision  of  the  hip-joint.    (Stimson.) 

the  wound.  A  transverse  section  of  the  bone  is  then  made 
with  a  saw  just  below  the  great  trochanter.  In  some  cases 
it  is  difficult  to  remove  the  head  of  the  bone,  which  may 
be  anchylosed  firmly  to  the  acetabulum ;  here  the  bone 
may  first  be  divided  with  a  chain-saw  passed  around  the 
femur  just  below  the  great  trochanter,  or  may  be  divided 
with  a  chisel,  the  head  and  neck  of  the  bone  afterward 
being  removed  with  a  gouge  or  bone-forceps. 

35 


546 


EXCISIONS  OR  RESECTIONS. 


Anterior  Excision  of  the  Hip. — In  this  method  of  excis- 
ing the  hip-joint,  an  incision  is  made  upon  the  front  of  the 
thigh  over  the  joint,  beginning  half  an  inch  below  the 
anterior  superior  spine  of  the  ilium,  and  is  carried  three 
or  four  inches  downward  and  a  little  inward ;  as  the  incis- 
ion is  deepened  the  tensor  vaginae  femoris  and  the  glutei 
muscles  are  exposed,  and  should  be  drawn  to  the  outer 
side,  the  sartorius  and  rectus  muscles  are  held  to  the 
inner  side  and  the  neck  of  the  femur  exposed  ;  the  neck  of 
the  bone  is  then  divided  with  a  metacarpal  saw  or  Adams' 
saw,  the  diseased  portion  of  the  bone  is  next  grasped  with 
strong  sequestrum  forceps,  and  by  the  use  of  these  and  an 
elevator  the  head  of  the  bone  is  removed. 

Excision  of  the  Knee-joint. — The   knee-joint  is  ex- 
cised by  making  an  incision  which  begins  at  the  inner 

Fig.  455. 


Incision  for  excision  of  the  knee-joint.    A.  Curved  incision.    B.  Angular 
incision.    (Stimson.) 


side  of  the  limb  over  the  inner  condyle  of  the  femur,  and 
is  carried  over  the  front  of  the  knee  just  below  the 
patella  to  a  corresponding  point  upon  the  external  condyle 
of  the   femur  (Fig.  455,  A),  or  by  an  angular  incision 


EXCISION  OF  THE  PATELLA.  547 

(Fig.  455,  B).  The  flap  thus  formed  is  dissected  up  to  a 
point  corresponding  with  the  upper  edge  of  the  patella, 
the  ligamentum  patellae  is  then  cut  through,  the  leg  is 
slightly  flexed,  and  the  joint  is  opened  ;  the  lateral  liga- 
ments are  then  divided,  and  by  flexing  the  leg  upon  the 
thigh  the  joint  is  freely  exposed.  The  semilunar  cartilages 
are  next  removed  and  the  condyles  of  the  femur  are  freed  ; 
a  narrow-bladed  saw  is  placed  under  the  condyles  and  a 
transverse  section  of  the  condyles  is  removed  ;  the  head 
of  the  tibia  is  next  cleared,  and  a  transverse  section  of  this 
bone  is  also  removed  with  a  saw.  The  patella  may  be 
removed  before  excising  the  ends  of  the  bone,  or,  if  anchy- 
losed  to  the  condyles,  may  be  removed  with  the  section 
of  bone  which  removes  a  portion  of  the  condyles.  In 
excising  the  knee-joint  in  young  persons,  care  should  be 
taken  to  remove  only  so  much  bone  as  may  be  done 
without  encroaching  upon  the  lines  of  epiphyseal  carti- 
lages, as  removal  of  the  epiphyseal  cartilage  would  inter- 
fere with  the  subsequent  growth  of  the  bones. 

Arthrectomy  of  the  Knee-joint. — This  operation  is 
employed  as  a  substitute  for  the  operation  of  excision  in 
disease  of  the  knee-joint,  and  is  performed  by  exposing 
the  joint  by  an  incision  similar  to  that  employed  in  excis- 
ion. The  ligamentum  patella?  is  divided  and  the  patella 
is  reflected  with  the  skin  flap.  When  the  joint  has  been 
freely  exposed,  the  diseased  articular  cartilages,  semilunar 
cartilages,  crucial  ligaments,  and  synovial  pouches  are 
removed  by  the  use  of  the  knife  or  scissors  and  the 
curette ;  if  the  surface  of  the  bone  is  found  to  be  carious, 
it  is  removed  by  the  curette  or  gouge.  After  the  joint 
has  been  thoroughly  cleared  of  diseased  tissue  it  is  irri- 
gated, the  divided  ligamentum  patella?  is  sutured  with 
several  strands  of  chromicized  catgut  or  silk,  and  the 
wound  is  drained  and  closed. 

Excision  of  the  Patella. — The  patella  may  be  excised 
by  making  a  longitudinal  or  crucial  incision  ;  the  perios- 
teum is  carefully  separated  from  the  bone,  and  the  latter 
is  grasped  with  strong  forceps  and  dissected  free  from  its 
attachments   upon  the   under  surface.     The  knee-joint  is 


548 


EXCISIONS  OR  RESECTIONS. 


generally  opened  in  removing  the  patella,  unless  removal 
of  the  bone  be  undertaken  for  necrosis  or  caries,  when  it 
is  possible  to  accomplish  its  complete  removal  without 
opening  the  joint. 

Resection  of  the  Tibia  or  Fibula. — In  resecting  the 
tibia  or  fibula,  the  bones  may  be  exposed  by  a  longitudinal 
incision  over  the  bone  to  be  removed,  and  after  the  shaft 
of  the  bone  has  been  exposed  and  the  periosteum  separated 

Fig.  456. 


Resection  of  lower  end  of  the  fibula. 


as  completely  as  possible,  the  shaft  of  the  bone  may  be 
divided  at  its  middle  and  each  fragment  grasped  with 
forceps  and  dissected  up,  and  removed  at  its  epiphyseal 
junction  (Fig.  456). 

Excision  of  the  Ankle  joint. — In  excising  the  ankle- 
joint,  an  incision  is  made  at  a  point  two  inches  above  the 
external  malleolus,  and  carried  downward  over  the  fibula 
to  the  tip  of  the  external  malleolus  ;  it  is  then  curved 
slightly  upward  toward  the  dorsum  of  the  foot  (Fig.  457), 


EXCISION  OF  THE  ASTRAGALUS. 


549 


care  being  taken  that  the  incision  does  not  extend  so  far 
forward  as  to  endanger  the  extensor  tendons  or  the  dorsal 
artery.  The  bone  is  exposed  in  this  incision  and  the 
periosteum  is  separated  and  turned  aside ;  the  peroneal 
tendons  are  next  exposed  and  held  to  one  side  by  retrac- 
tors;  the  external  malleolus  is  next  divided  by  bone-for- 
ceps and  removed,  and  the  astragalus  exposed.  The  upper 
articulating  surface  of  the  astragalus  is  next  removed  with 

Fig.  457. 


Incision  for  excision  of  the  ankle-joint.    (Stimson.) 


bone-forceps  or  a  saw,  or  the  whole  bone  may  be  removed. 
The  foot  is  next  inverted  and  the  end  of  the  tibia  cleared 
with  a  probe-pointed  knife,  care  being  taken  not  to  injure 
the  posterior  tibial  artery,  nerve,  or  vein ;  and  when  the 
articular  surface  has  been  freed,  it  is  removed  with  a  saw 
or  bone-forceps.  The  articular  end  of  the  tibia  may  be 
exposed  by  making  an  additional  incision  upon  the  inner 
side  of  the  ankle  over  the  internal  malleolus  if  desired. 
Excision  of  the  Astragalus. — In  excising  the  astraga- 


550  EXCISIONS  OR  RESECTIONS. 

lus,  a  semilunar  incision  is  made  upon  the  outside  of  the 
ankle-joint,  very  similar  to  that  employed  in  excising  the 
ankle ;  the  external  lateral  ligaments  are  divided  with  a 
probe-pointed  knife,  and  the  astragalus  is  exposed  by 
forcibly  inverting  the  foot ;  the  bone  is  then  seized  with 
strong  forceps,  its  ligamentous  attachments  are  divided 
with  a  probe-pointed  knife,  and  it  is  removed. 

Excision  of  the  Os  Calcis. — An  incision  is  made  at 
the  level  of  the  upper  part  of  the  bone,  beginning  at  the 
inner  border  of  the  tendo-Achilles,  dividing  this  tendon 
and  passing  around  the  back  and  outer  surface  of  the  foot 
to  the  base  of  the  fifth  metatarsal  bone ;  a  short  incision  is 
then  made  at  the  anterior  end  of  the  first  incision  and 
carried  down  to  the  sole  of  the  foot;  the  bone  is  exposed 
and  held  by  forceps ;  the  flap  thus  formed,  which  includes 
the  peronei  tendons,  is  then  separated  from  the  bone,  and 
the  cuboid  ligaments  are  cut  and  also  the  interosseous 
ligament  between  the  os  calcis  and  the  astragalus,  and  the 
bone  is  removed  with  forceps. 

Resection  of  the  Metatarsal  Bones. — Any  of  the 
metatarsal  bones  may  be  resected  by  an  incision  on  the 

Fig.  458. 


Incision  for  resection  of  the  metatarsal  bone  of  the  great  toe.    (Smith.) 

dorsum  of  the  foot  over  the  bone  to  be  removed  ;  the 
bone  is  exposed,  the  extensor  tendons  being  held  aside  by 
retractors ;  the  bone  is  disarticulated  at  either  end  or  is 
cut  in  its  middle,  and  each  fragment  dissected  up  and 
removed  at  its  articulation.  The  metatarsal  bone  of  the 
great  toe  is  exposed  by  making  a  curved  incision  over  that 
bone  on  the  inner  side  of  the  foot  (Fig.  458). 

Excision  of  the  Coccyx. — In  excising  the  coccyx,  the 
finger  is  passed  into  the  rectum  and  the  position  of  the 


EXCISION  OF  THE   UPPER  JAW. 


551 


bone  determined;  a  longitudinal  incision  through  the  skin 
and  fibrous  tissues  covering  the  coccyx  is  made  from  a 
point  about  a  quarter  of  an  inch  above  its  upper  limit, 
and  is  carried  down  to  a  little  below  its  lower  extremity. 
This  incision  may  be  supplemented  with  a  transverse  in- 
cision. The  sacro-coccygeal  articulation  is  then  opened  ;  an 
elevator  is  next  introduced  into  the  articulation  and  the 
bone  is  raised  up  and  grasped  with  forceps.  It  should 
then  be  freed  from  its  lateral  attachments,  and  those  upon 
its  anterior  surface,  with  the  knife  and  elevator. 

Excision  of  the  Upper  Jaw. — In  excising  one-half  of 
the  upper  jaw,  the  incision  is  begun  half  an  inch  below  the 

Fig.  459. 


Incision  for  excision  of  the  upper  jaw. 

inner  canthus  of  the  eye,  and  is  carried  downward  along 
the  line  of  junction  of  the  nose  and  cheek,  along  the  course 
which  limits  the  alse  nasi,  and  longitudinally  to  the  sep- 
tum, and  then  down  through  the  free  border  of  the  lip ;  it 
is  also  advisable  to  carry  the  incision  along  the  lower  edge 
of  the  orbit  outward  over  the  malar  bone  (Fig.  459) ;  the 
flap  being  dissected  away  from  the  surface  of  the  bone,  a 
small,  narrow  metacarpal  saw  is  then  applied  to  the  floor 
of  the  nostril  until  a  deep  groove  is  made ;  the  soft  palate 
and  the  tissue  covering  the  hard  palate  are  next  divided 


552  EXCISIONS  OB  RESECTIONS. 

from  within  the  mouth  with  a  strong  knife ;  one  or  two 
incisor  teeth  should  be  removed,  and  one  blade  of  a  pair 
of  strong  bone-forceps  introduced  into  the  floor  of  the 
nose  in  the  line  of  the  saw  incision,  the  other  blade  is 
introduced  into  the  mouth  in  the  line  of  the  division  of 
the  structures  of  the  palate,  and  the  bone  divided.  The 
malar  bone  is  next  divided  with  a  saw  or  forceps,  and, 
finally,  the  blades  of  a  strong  pair  of  bone-cutting  forceps 
are  introduced,  one  into  the  nostril  and  the  other  at  the 
edge  of  the  orbit,  the  important  structures  of  the  orbit 
being  held  upward  with  a  retractor,  and  the  inner  angle 
of  the  orbit  is  cut  across ;  the  superior  maxillary  bone  is 
then  grasped  with  strong,  lion-jawed  forceps  and  twisted 
out,  any  band  of  tissues  which  holds  it  being  divided  with 
the  knife  or  scissors. 

Excision  of  the  Lower  Jaw. — Partial  or  complete 
excision  of  the  lower  jaw  may  be  practised. 

Excision  of  the  Ramus  and  Half  of  the  Body  of  the  Lower 
Jaw. — The  incision  should  be  made  from  a  point  just  below 

Fig.  460. 


Incision  for  excision  of  the  lower  jaw. 

the  free  border  of  the  lip  over  the  symphysis,  and  carried 
down  to  the  lower  border  of  the  jaw,  and  from  this  point 


TREPHINING   THE  SKULL.  553 

it  is  carried  along  the  ramus  to  the  lobe  of  the  ear  (Fig. 
460);  the  flap  is  then  dissected  up,  separating  the  mas- 
seter  muscle  from  the  bone  as  far  as  possible  without 
opening  the  cavity  of  the  mouth  ;  an  incisor  tooth  is  next 
drawn  and  the  bone  is  sawed  through  near  the  symphysis  ; 
the  jaw  is  then  seized  with  forceps  and  drawn  downward 
and  forward  and  denuded  upon  its  inner  surface.  The 
insertion  of  the  temporal  muscle  into  the  coronoid  process 
is  divided,  the  condyle  of  the  jaw  is  disarticulated  from 
the  glenoid  cavity,  and  the  remaining  soft  parts  carefully 
detached  with  a  knife  or  elevator.  The  facial  artery  and 
the  inferior  dental  nerve  and  artery  are  necessarily  divided 
in  removing  this  portion  of  the  jaw. 

Partial  Excision  of  the  Lower  Jaw  or  Alveolus. — The  re- 
moval of  a  portion  of  the  alveolar  process  of  the  jaw  may 
often  be  accomplished  through  the  mouth  without  the  aid 
of  a  cutaneous  incision.  The  condyle,  of  the  jaw  may  be 
excised  by  making  an  incision  close  in  front  of  the  tem- 
poral artery  and  carrying  it  forward  along  the  zygoma 
for  an  inch  and  a  half;  the  tissues  being  divided  and  the 
bone  exposed,  a  second  incision  involving  only  the  skin  is 
then  carried  from  the  centre  of  the  first  directly  down- 
ward for  about  an  inch  ;  the  soft  parts  are  next  carefully 
separated  with  a  knife  and  elevator  from  the  margin  of 
the  zygoma  and  outer  surface  of  the  joint  and  drawn 
down wTard  with  a  retractor,  to  prevent  injury  of  the  parotid 
gland,  nerves,  and  vessels.  The  neck  of  the  condyle  is 
then  cleared  by  working  around  it  in  front  and  behind 
with  a  director,  keeping  close  to  the  bone  to  avoid  injury 
of  the  internal  maxillary  artery.  A  chain-saw  is  then 
passed  around  the  neck  of  the  bone,  which  is  divided,  and 
the  condyle  is  seized  with  forceps  and  removed  with  an 
elevator  or  gouge. 

TREPHINING  THE  SKULL. 

This  is  an  operation  in  which  a  circular  disk  of  bone  of 
the  skull  is  removed  by  a  circular  saw  or  trephine  to  ex- 
pose the  membranes  and  the  brain.     If  a  wound  is  already 


554  EXCISIONS  OB  RESECTIONS. 

present  in  the  scalp,  exposing  the  skull,  as  in  the  case  of 
compound  fracture  of  the  skull,  it  is  exposed  and  bared, 
so  that  the  crown  of  the  trephine  may  be  placed  fairly  on 
the  bone ;  if  no  wound  exists,  a  U-shaped  flap  is  made, 
including  all  the  structures  down  to  the  bone.  The  base 
of  the  flap  should  be  so  situated  as  to  contain  a  sufficient 
blood-supply,  and  the  flap  should  be  so  planned  as  to  favor 
drainage  from  the  wound.  When  the  bone  has  been  ex- 
posed, the  trephine  is  placed  with  the  centre  pin  projecting 
about  one-sixteenth  of  an  inch,  and  the  instrument  is  turned 
from  right  to  left  until  a  groove  is  made  in  the  bone ;  the 
trephine  is  then  removed,  and  the  centre  pin  is  raised  so 

Fig.  461. 


Trephine. 

that  as  the  teeth  of  the  trephine  approach  the  inner  table 
of  the  skull  the  point  of  the  centre  pin  will  not  injure  the 
membranes  or  brain.  The  instrument  is  then  reapplied 
and  worked  cautiously  as  the  groove  in  the  bone  is  deep- 
ened. When  the  diploe  is  reached,  there  is  usually  some 
bleeding  from  the  wound,  and  as  the  trephine  approaches 
the  inner  table  of  the  skull  it  should  be  manipulated  with 
great  care,  and  when  the  resistai^ce  is  felt  to  diminish  at 
any  one  part  of  the  bone  the  trephine  is  made  to  cut  at 
other  points  of  the  bone  where  resistance  is  still  apparent. 
When  the  disk  is  completely  cut  through,  it  may  be  lifted 
out  in  the  crown  of  the  trephine  or  may  be  removed  with 
forceps  or  an  elevator.     If  the  opening  in  the  skull  has  to 


TREPHINING   THE  SKULL. 


555 


be  enlarged  to  obtain  greater  exposure  of  the  membranes 
or  brain,  it  may  be  done  very  satisfactorily  with  a  form 
of  rongeur  forceps. 

A  portion  of  the  skull  may  also  be  removed  by  the  use 
of  the  gouge  and  mallet;  the  gouge  is  generally  preferred 
to  the  trephine  in  opening  the  mastoid  cells. 


Fig.  462. 


1.  Trephine  opening  for  mastoid  antrum.  2.  For  abscess  from  otitis  media. 
3.  To  expose  cerebellum.  4,  5.  For  middle  meningeal  hemorrhage.  A.  Lateral 
sinus.    B  and  C.  Limit  of  up  and  down  variation.    (Stimson.) 

When  the  trephine  is  applied  to  expose  the  seat  of  hem- 
orrhage from  the  middle  meningeal  artery,  or  hemorrhage 
from  the  lateral  sinus,  or  an  abscess  from  middle-ear  dis- 
ease, or  to  open  the  mastoid  antrum,  the  positions  for  the 
application  of  the  trephine  are  indicated  in  Fig.  462. 


556  EXCISIONS  OR  RESECTIONS. 

Osteoplastic  Resection  of  the  Skull. — In  this  opera- 
tion for  exposing  the  membranes  of  the  brain,  a  portion 
of  the  skull  having  the  soft  parts  attached  is  turned 
aside,  so  that  it  may  subsequently  be  replaced  and  sutured 
in  its  original  position.  The  operation  is  frequently 
employed  to  expose  the  ganglia  at  the  base  of  the  brain 
and  in  the  removal  of  tumors  of  the  brain.  A  horseshoe- 
shaped  incision  is  made,  and  the  edges  are  allowed  to  retract 
(Fig.  463).  A  groove  is  next  cut  through  the  bone,  fol- 
lowing the  line  to  which  the  skin  flap  has  retracted,  with 
a  chisel  or  with  a  circular  saw  run  by  a  dental  engine  or 
electric  motor.  The  line  of  division  of  the  bone  should 
be  oblique,  so  that  the  outer  table  of  the  flap  rests  upon 
the  inner  table  of  the  skull  when  the  bone  flap  is  turned 
back  into  place.  The  base  of  the  bone  flap  is  then  partly 
divided  with  the  chisel,  with  as  little  disturbance  of  the 
soft  parts  as  possible,  and  the  remaining  bone  in  the  base 
of  the  flap  is  broken  and  the  flap  turned  back,  the  scalp 
acting  as  a  hinge  (Fig.  464). 

Gigli's  wire  saw  may  be  used  in  operating  upon  the 
skull.  Two  small  trephine  openings  are  made,  and  a  flat 
director  passed  into  one  of  the  openings,  to  separate  the 
dura  on  a  line  between  them,  and  the  wire  saw  drawn 
through  this  space  by  a  thread  attached  to  a  flexible  silver 
probe.  The  bridge  of  bone  is  then  divided  by  the  saw. 
Any  desired  amount  of  bone  can  be  removed  by  making 
three  or  four  trephine  openings  and  sawing  between  them. 

If  the  osteoplastic  flap  method  is  employed,  the  skin  is 
left  undivided  on  one  side  and  adherent  to  the  bone  flap, 
and  the  saw  is  made  to  cut  the  bridge  of  bone  between 
the  trephine  openings  obliquely,  so  as  to  bevel  the  edges 
of  the  flap. 

An  instrument  for  osteoplastic  resection  or  trephining 
of  the  skull,  which  accomplishes  the  object  more  rapidly, 
has  recently  been  introduced  by  Dr.  T.  C.  Stellwagen,  Jr. 

Trephining  the  Antrum  of  Highmore. — The  antrum 
may  be  opened  by  extracting  the  first  or  second  molar  tooth 
and  deepening  its  socket  with  a  small  gouge  or  bone  drill. 

The  antrum  may  also  be  opened  through  the  mouth,  to 


OSTEOPLASTIC  RESEi  Tiny  OF  THE  SKULL.     557 
Fig.  463. 


Fig.  464. 


Osteoplastic  resection  of  the  skull.    (After  Treves.) 


558  EXCISIONS  OB  RESECTIONS. 

avoid  a  scar  upon  the  face,  by  the  use  of  a  small  trephine 
or  bone-gouge ;  the  gingivo-labial  fold  is  divided  up  to  a 
point  just  below  the  infra-orbital  foramen,  the  trephine 
is  placed  here,  and  a  disk  of  bone  removed,  opening  the 
antrum. 

Trephining  the  Frontal  Sinus. — This  sinus  may  be 
opened  by  a  trephine  or  bone-gouge.  An  incision  is  made 
from  the  centre  of  the  supra-orbital  ridge  to  the  median 
line  above  the  root  of  the  nose.  The  tissues  are  divided 
down  to  the  periosteum  ;  this  is  incised  and  turned  aside, 
the  trephine  or  gouge  is  placed  at  the  centre  of  the  incision 
near  the  inner  edge  of  the  supra-orbital  ridge  and  a  disk 
of  bone  is  removed,  exposing  the  frontal  sinus. 

LAMINECTOMY. 

This  operation,  which  consists  in  exposing  and  cutting 
away  the  arches  of  the  vertebrae,  to  secure  a  free  exposure 
of  the  spinal  canal  and  cord,  is  resorted  to  in  cases  of 
fracture  of  the  vertebrae,  tumors  of  the  spinal  cord,  and 
in  cases  of  tuberculosis  of  the  spine  in  which  there  is 
marked  deformity  with  paralysis,  the  object  being,  as  a 
rule,  to  relieve  the  spinal  cord  from  pressure.  A  straight 
incision,  four  or  five  inches  in  length,  is  made  over  the 
point  at  which  the  arches  of  the  vertebrae  are  to  be 
removed,  and  the  skin,  muscles,  and  fascia  are  divided, 
and  the  spinous  processes  and  arches  of  the  vertebrae  are 
laid  bare.  Then  with  strong  bone-forceps  the  arches  of 
the  vertebrae  on  each  side  are  divided,  care  being  taken  to 
avoid  injuring  the  dura.  A  better  method  is  the  forma- 
tion of  a  lateral  flap  by  an  incision  over  the  arches  upon 
one  side,  the  periosteum  and  muscles  being  reflected  to  the 
base  of  the  spinous  processes,  the  latter  then  being  divided 
with  bone-forceps  or  chisel  and  lifted  up  in  the  flap,  the 
dissection  of  which  is  continued  toward  the  other  side 
until  the  arches  are  exposed  from  end  to  end.  The  latter 
are  then  cut  away.  It  is  often  necessary  to  remove  several 
laminae  if  any  considerable  amount  of  the  spinal  cord  or 
canal  is  to  be  exposed. 


OPERATIONS   UPON  NERVES.  559 

OPERATIONS  UPON  NERVES. 

Neurotomy. — Neurotomy  is  an  operation  in  which  the 
nerve-trunk  is  exposed  and  a  section  made  through  the 
nerve.  As  in  the  case  of  ligation  of  vessel.-,  it  is  most 
important  that  the  operator  should  have  an  accurate 
knowledge  of  the  anatomical  relations  of  the  nerves  and 
the  surrounding  structures.  The  nerve  is  exposed  by  an 
incision  similar  to  that  for  the  exposure  of  an  artery  for 
the  application  of  a  ligature. 

Nerve-stretching,  or  Neurectasy.— In  the  operation 
of  neurectasy,  or  stretching  of  nerves,  the  nerve  is  exposed 
and  isolated  and  is  lifted  upon  a  blunt  hook  or  retractor ; 
or,  in  case  of  the  larger  nerves,  is  hooked  out  of  the  wound 
by  the  finger,  and  is  thoroughly  stretched  and  replaced  in 
the  wound,  and  the  latter  closed  with  sutures. 

Neurectomy. — In  this  operation  the  nerve  is  exposed 
and  a  portion  of  the  nerve  is  excised. 

Suture  of  Nerves,  or  Neurorrhaphy. — In  bringing 
into  apposition  the  ends  of  divided  nerves,  primary  or  sec- 
ondary sutures  may  be  employed.  The  material  emploved 
for  sutures  should  be  fine  silk  or  fine  chromicized  catgut. 
In  using  primary  sutures,  the  suture  in  the  case  of  the 
smaller  nerves  should  be  passed  through  the  sheath  and 
substance  of  the  nerve,  and  in  the  larger  nerves  two  sets 
of  sutures  may  be  used,  one  passing  through  the  substance 
of  the  nerve,  the  other  through  the  sheath. 

Nerve -grafting. — In  employing  secondary  sutures  to 
unite  the  divided  ends  of  nerves  when  there  has  been  a 

Fig.  465. 


Nerve-grafting.     (Willard.) 


loss  of  substance  in  the  nerve,  or  there  has  been  so  much 
retraction  of  the  nerve  that  it  is  impossible  to  bring  the 
ends  together,  nerve-grafting  may  be  made  use  of;  the 
ends  of  the   nerve   being  freshened,  a  section  of  a  fresh 


560  NEUROPLASTY. 

nerve  from  an  amputated  limb  or  animal  is  sutured  to  the 
ends  of  the  divided  nerve  to  fill  up  the  gap,  as  seen  in 
Fig.  465. 

Nerve -implantation. — This  operation  consists  in  sutur- 
ing a  healthy  nerve,  either  in  whole  or  in  part,  to  a  para- 
lyzed one.  Implantation  is  practised  by  inserting  the  cut 
end  of  a  nerve  into  an  incision  made  into  the  sheath  of  an 
adjacent  nerve  and  securing  it  in  this  position  by  sutures. 
Both  the  upper  and  lower  ends  of  a  nerve  may  be  implanted 
into  a  neighboring  nerve  in  this  manner. 

Neuroplasty. — Another  method  of  lengthening  the 
ends  of  a  divided  nerve,  known  as  neuroplasty,  may  be 
employed  where  the  ends  cannot  be  brought  into  apposi- 
tion by  the  ordinary  method ;  in  this  method  flaps  are 
made  for  the  nerve  in  the  same  way  as  in  the  lengthening 
of  shortened  tendons,  and  the  ends  of  the  flaps  are  sutured 

Fig.  466. 


Neuroplasty.     (Willard.) 

together,  as  seen  in  Fig.  466.  Sutures  a  distance'  may 
also  be  employed,  as  in  the  case  of  the  separated  ends  of 
tendons. 

The  following  incisions  are  given  to  expose  the  nerves 
for  some  of  these  various  operations  : 

The  Supra-orbital  Nerve. — This  nerve  is  exposed  at  the 
supra-orbital  notch  at  the  junction  of  the  middle  and 
inner  thirds  of  the  supra-orbital  arch.  An  incision  is 
made  one  and  a  half  inches  in  length,  parallel  to  the  eye- 
brow (Fig.  467,  A  and  B),  and  is  carried  down  to  the 
bone ;  the  nerve  is  exposed  and  grasped  with  forceps,  and 
resected  or  stretched  as  may  be  desired. 

The  Superior  Maxillary  Nerve. — A  vertical  incision  is 
made  along  the  inner  side  of  the  nose  from  the  bony  ridge 
of  the  nasal  process  of  the  superior  maxillary  bone  to  the 
ala  of  the  nose  ;  a  second  incision  is  begun  at  the  upper 
part  of  this  incision  and  carried  outward  along  the  lower 
margin  of  the  orbit   beyond  its  centre  (Fig.  467,  C) ;  the 


OPERATIONS   UPON  NERVES 


561 


lower  flap  is  dissected  up  and  the  infra-orbital  nerve  ex- 
posed. The  upper  flap  is  next  lifted  up  with  the  lower 
eyelid  and  eyeball,  exposing  the  floor  of  the  orbit,  and  the 
infra-orbital  canal  may  be  recognized  running  backward 
and  inward ;  the  canal  is  opened  with  a  knife  or  chisel, 
and  the  nerve  separated  from  the  artery  and  cut  off  as  far 
back  as  may  be  necessary.  The  nerve  may  also  be  reached 
by  exposing  the  anterior  wall  of  the  antrum,  and  trephin- 
ing this  and  the  posterior  wall,  and,  when  found,  may  be 
cut  off  close  to  the  exit  of  the  main  trunk  from  the  round 
foramen  in  the  sphenoid  bone. 

Fig.  407. 


A  and  B.  Incisions  for  resection  of  supraorbital  nerve.     C.  Incision  for 
resection  of  the  superior  maxillary  nerve. 


The  Inferior  Dental  Nerve. — To  expose  this  nerve,  an 
incision  is  made  along  the  lower  jaw,  from  a  point  just 
behind  the  angle,  and  carried  forward  to  a  point  just  in 
front  of  the  edge  of  the  masseter  muscle  ;  the  periosteum 
and  masseter  muscle  are  then  separated  from  the  bone 
with  an  elevator,  and  the  inferior  dental  canal  opened 
with  a  small  trephine  or  chisel  ;  the  exposed  nerve  is  then 
raised  upon  a  hook  and  resected. 

The  Lingual  Nerve. — The  lingual  nerve  may  be  felt  just 
behind  the  attachment  of  the  pterygo-maxillary  ligament, 
on  the  inner  side  of  the  lower  jaw,  close  to  the  bone,  below 
the  last  molar  tooth  ;  the  tongue  should  be  drawn  to  one 

36 


562 


OPERATIONS   UPON  NERVES. 


side  and  the  mucous  membrane  divided  for  an  inch,  par- 
allel to  the  alveolar  process,  beginning  at  the  last  molar 
tooth ;  the  nerve  is  then  found  in  the  submucous  tissue. 

The  Facial  Nerve. — This  nerve  may  be  exposed  at  the 
posterior  border  of  the  ramus  of  the  jaw  by  an  incision 
extending  from  just  in  front  of  the  tragus  of  the  ear  to  the 
angle  of  the  jaw.  The  parotid  fascia  is  divided,  the  cervico- 
facial branch  is  exposed  first,  and  may  be  followed  back 
to  its  junction  with  the  temporo-facial  branch. 

The  Brachial  Plexus. — The  brachial  plexus  consists  of 
the  four  lower  cervical  nerves  and  the  greater  part  of  the 

Fig.  468. 


Resection  of  the  brachial  plexus. 

first  dorsal ;  it  lies  between  the  anterior  and  middle  scaleni 
muscles  and  crosses  the  floor  of  the  subclavian  triangle  at 
the  base  of  the  neck.  To  expose  the  brachial  plexus,  the 
neck  and  head  are  extended  and  the  face  turned  toward 
the  opposite  side ;  an  incision  is  made  half  an  inch  above 
the  clavicle,  between  the  sterno-cleido-mastoid  and  trape- 
zius muscles,  and  carried  forward  for  about  three  inches 
parallel  to  the  anterior  border  of  the  trapezius.     The  skin 


OPERATIONS    UPON  NERVES.  563 

and  platysma  are  divided,  and  the  external  jugular  vein 
is  either  cat  and  Ligated  or  held  to  one  side ;  the  deep 
cervical  fascia  is  next  opened  in  the  line  of  the  external 
incision,  and  the  outer  border  of  the  anterior  scalene 
muscle  felt  for;  the  brachial  plexus  is  found  just  outside 
the  latter,  and  is  exposed  by  careful  dissection  (Fig.  468). 

The  Spinal  Accessory  Nerve. — To  expose  the  spinal  acces- 
sory nerve,  an  incision  about  three  inches  in  length  is  made 
downward  from  the  tip  of  the  mastoid  process  along  the 
anterior  border  of  the  sterno-mastoid  muscle  ;  the  cervical 
fascia  should  be  divided  and  the  muscle  strongly  retracted, 
to  put  the  nerve  on  the  stretch.  The  nerve  should  be 
found  external  to  the  jugular  vein,  about  an  inch  and  a 
half  below  the  tip  of  the  mastoid  process,  on  the  fascia 
covering  the  rectus  capitis  anticus  major. 

The  Median  Nerve. — The  median  nerve  may  be  exposed 
at  the  bend  of  the  elbow  or  just  above  the  wrist.  To 
expose  the  median  nerve  at  the  bend  of  the  elbow,  an 
incision  is  made  about  an  inch  and  a  half  in  length  upon 
the  inner  edge  of  the  biceps  tendon  ;  the  bicipital  fascia  is 
divided  and  the  nerve  exposed  at  the  inner  side  of  the 
brachial  artery.  The  median  nerve  may  also  be  exposed 
above  the  wrist  by  an  incision  two  inches  in  length  along 
the  inner  border  of  the  tendon  of  the  palmaris  longus 
muscle. 

The  Ulnar  and  Radial  Nerves. — These  nerves  may  be 
exposed  by  an  incision  similar  to  that  employed  for  liga- 
tion of  the  ulnar  or  radial  artery. 

The  Musculo- spiral  Nerve. — The  musculo-spiral  nerve  is 
exposed  by  an  incision  on  the  outer  side  of  the  arm  above 
the  elbow,  from  the  upper  part  of  the  supinator  groove ; 
the  fascia  being  divided,  the  nerve  is  sought  foi"  at  the 
bottom  of  this  groove. 

The  Great  Sciatic  Nerve. — To  expose  the  great  sciatic 
nerve,  an  incision  three  or  four  inches  in  length  is  made 
vertically  downward  from  the  gluteal  fold  at  a  point  mid- 
way between  the  tuberosity  of  the  ischium  and  the  great 
trochanter ;  the  skin  and  fascia  being  divided,  the  lower 
border  of  the  gluteus  maximus  and  the  hamstring  muscles 


564  OPERATIONS   UPON  TENDONS. 

are  exposed ;  the  nerve  rests  on  the  external  rotators  of 
the  thigh  just  in  front  of  the  outer  side  of  the  hamstring 
muscles. 

The  Internal  Popliteal  Nerve. — This  nerve  is  exposed  by 
an  incision  two  inches  in  length  in  the  middle  of  the  pop- 
liteal space.  The  nerve  is  slightly  external  to  the  vein 
and  artery,  and  is  more  superficially  placed. 

The  External  Popliteal  Nerve. — This  nerve  is  exposed  by 
an  incision  two  inches  in  length,  parallel  and  close  to  the 
inner  side  of  the  biceps  tendon,  and  lies  close  behind  and 
to  the  inner  side  of  this  tendon. 

The  Anterior  Crural  Nerve. — This  nerve  is  exposed  by 
an  incision  about  two  inches  in  length,  extending  from 
Poupart's  ligament  downward,  and  about  an  inch  to  the 
outer  side  of  the  femoral  artery. 


OPERATIONS  UPON  TENDONS. 

Tenotomy. — This  operation  consists  in  the  division  of 
a  tendon,  and  it  may  be  done  subcutaneously  or  by  an 
open  operation.  The  former  method  of  tenotomy  is  to  be 
preferred  in  most  cases,  but  in  certain  tendons  which  lie 
in  close  proximity  to  important  vessels  and  nerves  it  is 
safer  to  employ  the  open  operation.  In  dividing  tendons, 
the  parts  should  be  placed  in  such  a  position  as  to  render 

Fig.  469. 


Sharp-pointed  tenotome. 

the  tendons  tense.  The  instruments  required  are  a  sharp- 
and  a  blunt-pointed  tenotome.  The  sharp-pointed  ten- 
otome (Fig.  469)  is  used  to  make  a  puncture  down  to  the 
edge  of  the  tendon,  being  entered  flatwise  ;  it  is  then  with- 
drawn and  a  blunt-pointed  tenotome  (Fig.  470)  introduced 
through  the  puncture,  passed  under  the  tendon,  and  turned 
so  that  the  tendon  rests  upon  its  cutting  edge ;  by  a  gentle 


OPERATIONS   UPON  TENDONS. 


565 


rocking  motion   the  tendon  is  then  divided,  and  the  ten- 
otome turned  flatwise  and  withdrawn. 


Fig.  470. 


Blunt-pointed  tenotomes. 


The  Tendo-Achillis. — In  dividing  this  tendon,  a  sharp- 
pointed  tenotome  should  be  entered  at  the  inner  border 
of  the  tendon  about  an  inch  above  its  attachment  to  the 
calcaneum   (Fig.  471)  ;  the  heel   should   be  depressed  as 


Fig.  471. 


Tenotomy  of  tendo-Achillis. 

much  as  possible,  so  as  to  make  the  tendon  prominent,  and 
a  sharp-pointed  tenotome  passed  through  the  skin  and 
behind  the  tendon  ;  it  is  next  withdrawn  and  a  blunt- 
pointed  tenotome  introduced  and  the  tendon  divided.  The 
posterior  tibial  artery,  nerve,  and  vein  lie  to  the  inner  side, 
and  are  not  likely  to  be  injured  if  the  tendon  is  divided 
at  this  point. 

The  Posterior  Tibial  Tendon. — This  tendon  may  be 
divided  above  the  inner  malleolus.  The  muscle  is  made 
tense  by  everting  the  foot,  and  the  tenotome  is  entered  at 
the  inner  side  of  the  tendon  and  passed  behind  it.  The 
posterior  tibial  tendon  may  also  be  divided  upon  the  side 
of  the  foot ;  for  this  operation  the  foot  is  everted,  and  the 
tenotome  is  passed  from   above  downward  and  under  the 


566  OPERATIONS   UPON  TENDONS. 

upper  border  of  the  tendon  at  a  point  half  an  inch  below 
and  in  front  of  the  tip  of  the  internal  malleolus. 

The  Anterior  Tibial  Tendon. — This  tendon  is  divided 
upon  the  dorsal  surface  of  the  foot,  just  below  the  an- 
nular ligament  of  the  ankle,  midway  between  the  two 
malleoli. 

The  Peroneal  Tendons. — The  peroneal  tendons  may  be 
divided  about  an  inch  above  the  external  malleolus,  the 
tenotome  being  passed  from  before  backward  between  the 
fibula  and  the  tendons,  or  the  tendons  may  be  divided  at 
a  point  midway  between  the  end  of  the  external  malleolus 
and  the  tubercle  of  the  cuboid. 

The  Hamstring  Tendons. — The  inner  hamstring  consists 
of  the  tendons  of  the  semi-tendinosus,  semi-mem branosus, 
gracilis,  and  sartorius.  The  external  hamstring  consists 
of  the  tendon  of  the  biceps.  To  divide  either  of  these 
tendons,  the  knife  is  entered  at  the  inner  side  of  the  tendon. 
In  dividing  the  external  hamstring,  care  should  be  taken 
to  keep  close  to  the  tendon  of  the  biceps,  as  the  external 
popliteal  nerve  lies  close  to  its  inner  border. 

The  Adductor  Longus. — To  divide  this  tendon,  abduct 
the  thigh  and  make  the  muscle  prominent  near  its  inser- 
tion ;  then  pass  the  tenotome  from  without  downward  and 
inward. 

The  Flexor  Longus  Pollicis. — This  tendon  may  be  divided 
on  the  first  phalanx  or  near  the  inner  edge  of  the  foot, 
where  it  may  be  made  prominent  by  strong  extension  of 
the  great  toe,  the  tenotome  being  passed  close  to  the  border 
of  the  tendon. 

The  Extensor  Longus  Digitorum. — These  tendons  are 
divided  upon  the  dorsal  surface  of  the  metatarsal  bones, 
where  they  are  quite  prominent.  They  may  also  be 
divided  near  the  ankle. 

The  Extensor  Proprius  Pollicis. — This  tendon  may  be 
divided  in  the  same  incision  used  for  division  of  the  long 
extensor  of  the  toes,  the  point  of  the  knife  being  carried 
inward. 

The  Sterno-cleido-mastoid  Muscle. — In  tenotomy  of  this 
muscle,  the  sternal  and  clavicular  attachments  are  divided 


SUTURE  OF  TENDONS. 


567 


about  an  inch  above  the  sternum  and  clavicle.  A  puncture 
is  made  to  the  outer  side  of  the  muscle  with  a  sharp  teno- 
tome, and  when  the  tendinous  expansion  of  the  muscle  is 
reached  it  is  withdrawn,  a  blunt  tenotome  substituted,  and 
the  structure  divided.  The  sternal  attachment  is  divided 
through  a  separate  puncture  in  the  same  way.  The  exter- 
nal jugular  vein  at  the  outer  border  of  the  muscle  is  to  be 
avoided.  The  division  of  the  muscle,  or  its  tendinous 
expansion  by  an  open  operation,  is  now  often  practised,  as 
there  is  less  risk  of  injuring  the  vein  by  this  procedure. 

Fio.  472. 


TVnotornv  of  sterno-mastoid. 


Suture  of  Tendons. — In  bringing  together  the  divided 
ends  of  tendons,  primary  or  secondary  sutures  are  em- 
ployed ;  primary  sutures  are  those  introduced  immediately 
after  the  injury,  and  secondary  sutures  are  those  intro- 
duced after  retraction  of  the  ends  has  occurred  and  the 
wound  has  healed. 

Primary  Suture  of  Tendons. — The  material  employed  for 
sutures  may  be  silk,  silkworm-gut,  catgut,  or  kangaroo- 
tendon,  and  one  or  more  sutures  should  be  used,  being 
passed  through  the  substance  of  the  ends  of  the  tendon 
and  secured  by  tying  ;  the  divided  sheath  of  the  tendon, 


568 


OPERATIONS   UPON  TENDONS. 


if  possible,  should  be  brought  together  by  fine  silk  sutures 
(Fig.  473).  Very  marked  retraction  of  the  ends  of  the 
tendon  is  liable  to  occur,  and  a  considerable  dissection  is 
often  required  to  bring  them  into  view. 

Fig.  473. 


Suture  passed  through  the  substance  of  the  ends  of  a  divided  tendon. 

When  there  is  difficulty  in  bringing  the  ends  of  the 
tendon  together,  and  the  sutures  are  apt  to  cut  out,  the 
form  of  suture  shown  in  Fig.  474  may  be  employed. 

Fig.  474. 


Tendon-suture  which  does  not  easily  tear  out.    (Stimson.) 


Secondary  Suture  of  Tendons. — In  applying  secondary 
sutures  to  tendons,  the  principal  difficulty  is  often  encount- 
ered in  bringing  the  ends  of  the  tendon  in  contact  and  in 
holding  them  successfully  in  this  position.  The  ends  of 
the  tendon  have  first  to  be  freshened,  and  this  maybe  done 
by  cutting  them  obliquely  and  introducing  a  suture  as 
shown  in  Fig.  475.  This  method  of  section  presents  a 
large  raw  surface  of  the  tendon  for  union. 

Lengthening  of  Tendons. — When  so  large  a  gap  exists 
between  the  ends  of  the  tendon  that  they  cannot  be  brought 


TRANSPLANTATION  OF  TENDONS.  569 

Fig.  475. 


Oblique  section  of  ends  of  tendon  to  increase  surface  of  contact.    (Stimson.) 

into  apposition,  a  plastic  operation  may  be  performed  upon 
their  ends,  which  often  overcomes  the  difficulty.  This 
consists  in  making  a  section  halfway  through  the  tendons, 
at  some  distance  from  their  ends,  and  splitting  them  toward 
their  divided  extremities,  and  then  turning  out  these  flaps 
and  securing  their  ends  by  means  of  sutures  (Fig.  476). 

Fig.  476. 


Lengthening  of  retracted  tendon  by  flaps.     (Stimson.) 

When  the  ends  of  the  tendon  are  so  widely  separated  that 
they  cannot  be  approximated,  sutures  a  distance  may  be 
employed.  These  consist  of  sutures  of  sterilized  silk  or 
chromicized  catgut  passed  between  the  ends  of  the  tendon 
and  tied,  the  sutures  acting  as  a  scaffolding  upon  which 
reparative  material  forms  between  the  separated  ends  of 
the  tendon. 

Transplantation  of  Tendons. — This  operation  consists 
in  altering  the  attachments  of  the  tendons  of  healthy 
muscles  so  as  to  have  them  fulfil  the  functions  of  those 


570  TRACHEOTOMY. 

which  are  paralyzed.  Four  methods  of  transplantation 
are  practised  :  first,  the  tendon  of  the  healthy  muscle  may 
be  completely  divided  and  the  upper  end  sutured  to  the 
paralyzed  tendon  ;  second,  the  tendon  of  the  paralyzed 
muscle  may  be  divided  and  the  lower  end  sutured  to  the 
healthy  one ;  third,  the  tendon  of  the  sound  muscle  may 
be  split,  one  end  remaining  attached  to  its  normal  insertion, 
and  the  other  sutured  to  the  paralyzed  tendon  ;  fourth, 
a  portion  or  the  whole  of  the  healthy  tendon  may  be 
implanted  subperiosteally  at  the  desired  point,  instead  of 
stitching  it  to  the  paralyzed  tendon. 


REMOVAL  OF  THE  BREAST. 

This  may  be  accomplished  by  making  a  circular  incision 
around  the  breast,  or  by  an  incision  starting  at  the  ante- 
rior edge  of  the  axilla  and  carried  around  the  breast  and 
brought  back  to  the  point  of  starting.  The  incision  is 
deepened  and  the  muscles  are  exposed,  and  the  breast  is 
dissected  free  from  the  muscles  and  removed.  The  axilla 
is  next  opened  and  any  enlarged  glands  are  removed. 
The  modern  operation  of  removal  of  the  breast  for  malig- 
nant disease  is  one  which  is  similar  to  that  employed  by 
Kocher  and  Halsted,  and  consists  in  removal  of  the  breast, 
with  the  pectoral  muscles  and  the  axillary  glands  and 
connective  tissue,  the  incision  being  very  extensive,  and 
extended  so  as  to  permit  of  the  removal  of  glands  situated 
above  the  clavicle. 

TRACHEOTOMY. 

This  operation  consists  in  dividing  the  tissues  over  the 
trachea  in  the  median  line  of  the  neck,  and  after  the  trachea 
has  been  exposed  it  is  opeued  by  dividing  two  or  three  of 
the  tracheal  rings. 

Under  certain  circumstances  the  operation  may  be  per- 
formed with  very  few  instruments  ;  but  if  the  surgeon  has 
the  choice,  he  will  find  it  convenient  to  have  at  hand  two 


TEA  CHEO  TOMY.  57 1 

small  scalpels,  one  short  grooved  director,  a  tenaculum, 
two  aneurism  needles  (which   may  be  used  as  retractors), 

one  pair  of  artery  forceps,  haemostatic  forceps,  two  pairs 
of  dissectiog-forceps,  a  pair  of  scissors,  a  sharp-pointed 
tenotome,  a  pair  of  tracheal  forceps,  a  tracheal  dilator, 
tracheotomy  tubes,  tapes,  ligatures,  sponges,  a  flexible 
catheter,  and  feathers.  The  director  should  be  short ;  the 
ordinary  grooved  director  is  too  long  to  use  with  satisfac- 
tion in  operating  upon  the  short  necks  of  children  ;  so 
that  I  use  a  shorter  and  somewhat  broader  one,  having  a 
bevelled  extremity,  which  allows  it  to  be  passed  with  ease 
between  the  different  layers  of  the  tissues  (Fig.  477). 

Fig.  477. 


Author's  tracheotomy  director. 

Haemostatic  forceps  are  also  useful  in  controlling  hem- 
orrhage during  the  operation  in  case  of  the  division  of 
vessels  which  bleed  freely,  when  the  operator  from  the 
urgencv  of  the  case  does  not  think  it  justifiable  to  ligate 
them  at  the  time  of  their  division.  They  may  also  be 
employed  under  similar  circumstances  to  elamp  the  isth- 
mus of  the  thyroid  gland  on  either  side  of  the  trachea 
when  it  becomes  necessary  to  divide  it  to  expose  the 
trachea. 

A  sharp-pointed  tenotome  is  the  instrument  I  prefer  to 
employ  in  opening  the  trachea,  as  its  sharp  point  enables 
it  to  be  easily  thrust  into  the  trachea. 

Tracheal  dilators  of  various  kinds  are  employed,  but 
the  most  satisfactory  tracheal  dilator  which  I  have  em- 
ployed is  that  of  Golding-Bird  (Fig.  478),  which  is  a 
self-retaining  instrument ;  the  blades  are  slipped  through 
the  tracheal  incision  and  are  then  expanded  by  turning 
the  screw  to  which  they  are  attached.  Trousseau's  tracheal 
dilator,  the  blades  of  which  are  introduced  through  the 


572 


TRACHEOTOMY. 


incision  in  the  trachea  and  are  expanded  by  bringing 
together  the  handles,  is  also  a  satisfactory  instrument  (Fig. 
479),  but  it  is  not  so  useful  as  Golding-Bird's  dilator,  as 
it  has  to  be  retained  in  position  by  the  hand.  Tracheal 
dilators  may  be  improvised  from  bent  hair-pins  or  pieces 
of  wire,  which  will  often  serve  a  useful  purpose  where 
ordinary  dilators  cannot  be  obtained. 


Fig.  478. 


Fig.  479. 


Golding-Bird's  tracheal  dilator. 


Trousseau's  tracheal  dilator. 


It  is  also  well  to  have  at  hand  a  number  of  pliable 
feathers,  to  be  used  in  clearing  the  trachea  or  larynx  of 
mucus  or  membrane  after  it  has  been  opened  ;  by  their  use 
this  object  may  be  accomplished  with  little  risk  of  injury 
to  the  mucous  membrane. 


Fig.  480. 


Tracheal  forceps. 

Tracheal  forceps,  which  are  constructed  with  a  double 
spring  and  curved  blades,  are  also  useful  in  removing 
membrane  or  foreign  bodies  from  the  larynx  above  the 
wound  or  from  the  trachea  below  the  tracheal  incision 
(Fig.  480). 

Tracheotomy-tubes  of  various  shapes  are  made  of  silver, 


POSITION  OF  PATIENT  FOR  TRACHEOTOMY.    573 

aluminum,  hard  and  soft  rubber,  but  the  tube  which  I 
consider  the  most  satisfactory  for  general  use  is  a  silver 
quarter-circle  tube  with  a  movable  collar  (Fig.  481),  and 
provided  with  a  fenestrated  guide  (Fig.  482).  A  satisfactory 
tracheotomy-tube  is  one  which  inflicts  the  least  possible 
injury  upon  the  mucous  membrane  of  the  trachea,  and  to 
insure  this  object  the  part  of  the  tube  within  the  trachea 
should  lie  exactly  in  its  axis,  and  its  free  extremity  should 
be  capable  of  as  little  movement  as  possible.  The  trache- 
otomy-tube is  held  in  position,  after  being  introduced,  by 


Fig.  481. 


Fig.  482. 


Silver  tracheotomy-tube. 


Silver  tracheotomy-tube  with 
fenestrated  guide. 


means  of  tapes  attached  to  the  shield  of  the  tube  and  tied 
around  the  neck. 

Position  of  Patient  for  Tracheotomy. — The  best  posi- 
tion in  which  to  place  the  patient  for  this  operation  is  one 
which  brings  the  neck  into  the  greatest  prominence,  and 
this  may  best  be  obtained  by  laying  the  patient  upon  his 
back  upon  a  firm  table  and  placing  under  the  shoulders  a 
round  cushion ;  or  an  empty  wine-bottle  or  a  roller-pin 
wrapped  in  towels,  will  answer  the  same  purpose  (Fig. 
483)  ;  or  the  head  may  be  held  over  the  edge  of  the  table. 
If  an  anaesthetic  is  not  used,  the  arms  should  be  held  by 
an  assistant,  which   is  better  than  securing   them   by  a 


574 


TRACHEOTOMY. 


binder  around  the  chest,  which  restricts  respiratory  move- 
ments. 

Fig.  483. 


Position  of  patient  for  tracheotomy. 


Operation  of  Tracheotomy. — The  trachea  may  be 
opened  above  the  isthmus  of  the  thyroid  gland  or  below 
it,  and  these  operations  constitute  respectively  the  high 
and  the  low  operation. 

The  high  operation  is  generally  selected,  because  at  this 
point  the  trachea  is  more  superficial  and  is  more  easily 
exposed,  whereas  in  the  low  operation  the  trachea  is  more 
difficult  to  expose  by  reason  of  its  relatively  greater  depth, 
the  large  size  and  number  of  veins,  and  its  proximity  to 
the  large  arterial  trunks. 

High  Operation. — The  patient  being  placed  in  position, 
the  operator  stands  at  the  head  of  the  patient;  this  posi- 
tion I  prefer,  as  it  is  easier  from  this  point  to  keep  the 
incisions  exactly  in  the  median  line  of  the  neck.  The 
operator  next  makes  himself  familiar  with  the  landmarks 
of  the  neck;  locating  the  position  of  the  cricoid  cartilage, 
he  makes  an  incision  through  the  skin  in  the  median  line 
of  the  neck  from  one  and  a  half  to  two  inches  in  length, 
the  position  of  the  cricoid  cartilage  being  the  middle  point. 
There  is  no  disadvantage  in  making  a  longer  incision  if  a 
freer  exposure  of  the  parts  is  required.     Having  divided 


OPERATION  OF  TRACHEOTOMY.  575 

the  skin,  the  operator  will  often  see  a  large  vein  lying  in 
the  superficial  fascia — the  superficial  anterior  jugular; 
this  should  be  displaced  and  the  fascia  divided  upon  a 
director. 

The  surgeon  should  keep  his  incisions  strictly  in  the 
median  line  of  the  neck,  for  this  is  the  line  of  safety  ;  and 
he  should  be  careful,  as  the  wound  increases  in  depth,  not 
to  make  the  incisions  too  short,  so  that  the  wound  becomes 
funnel-shaped.  When  the  deep  fascia  is  exposed,  it  should 
be  picked  up  and  divided  upon  a  director  ;  any  large  veins 
in  the  line  of  the  wound  should  be  carefully  displaced,  or, 
if  this  is  impossible,  they  should  be  ligated  on  each  side 
and  then  divided  between  the  ligatures. 

The  operator  next  looks  for  the  intermuscular  space 
between  the  sterno-hyoid  and  the  ster  no-thyroid  muscles, 
which  may  generally  be  found  without  difficulty;  the  mus- 
cles are  now  separated  in  this  line,  with  the  handle  of  the 
knife  or  with  a  director,  and  the  isthmus  of  the  thyroid 
gland  exposed.  The  muscles  should  now  be  held  aside 
by  retractors  placed  on  either  side.  He  should  carefully 
explore  the  wound  with  the  finger,  to  locate  exactly  the 
position  of  the  trachea,  and  to  ascertain,  if  possible,  the 
presence  of  anomalous  arteries. 

The  isthmus  of  the  thyroid  gland  having  been  exposed, 
which  generally  occupies  a  position  over  the  first  three 
tracheal  rings,  the  gland  will  be  found  surrounded  by  a 
plexus  of  veins,  which  should  be  displaced  with  the  direc- 
tor ;  or,  if  this  is  impossible,  they  should  be  ligated  on 
each  side  and  divided  between  the  ligatures.  The  thyroid 
isthmus  is  next  displaced  upward  or  downward,  according 
as  the  surgeon  desires  to  open  the  trachea  below  or  above 
this  body.  This  is  often  done  without  difficulty,  especially 
its  upward  displacement;  but  when  there  is  difficulty  in 
displacing  it  downward,  a  procedure  recommended  by 
Bose  may  be  employed,  which  consists  in  making  a  trans- 
verse incision  across  the  cricoid  cartilage  to  divide  the 
layer  of  fascia  by  which  the  isthmus  is  bound  down ;  the 
director  is  then  passed  into  this  incision  and  the  isthmus 
is  depressed  without  difficulty. 


576 


TRACHEOTOMY. 


Having  displaced  the  isthmus  of  the  thyroid  gland 
downward,  the  trachea,  yellowish  white  in  appearance, 
covered  by  the  tracheal  fascia,  will  be  exposed;  this  fascia 
should  next  be  thoroughly  broken  up  with  a  director  or  the 
handle  of  the  knife,  so  as  to  bare  the  trachea,  and  in  doing 
this  the  operator  may  feel  it  crepitate  under  the  finger  from 
the  suction  of  air  drawn  in  with  inspiration.  The  trachea 
is  next  fixed  with  a  tenaculum,  introduced  into  it  a  little 
to  one  side  of  the  median  line;  an  incision  is  made  into 
it  with  a  narrow  knife  from  below  upward,  from  one- 
half  to  three-fourths  of  an  inch  in  length  (Fig.  484),  care 

Ftg.  484. 


Opening  the  trachea.     (Liston.) 

being  taken  to  see  that  this  incision  is  in  the  median  line, 
for  if  the  trachea  be  opened  by  a  lateral  incision  the 
wound  does  not  heal  so  promptly  and  the  tracheotomy- 
tube  does  not  fit  well,  and  its  lower  extremity  may  cause 
injury  to  the  mucous  membrane  of  the  trachea.  If  the 
wound  be  a  deep  one,  after  fixing  the  trachea  with  the 
tenaculum  the  operator  may  lift  it  slightly  from  its  bed, 
thereby  bringing  it  more  prominently  into  view  and  mak- 
ing it  more  superficial  in  the  wound,  thus  facilitating  its 
opening.    As  soon  as  the  incision  is  made  into  the  trachea, 


LARYNGOTOMY.  577 

air  mixed  with  blood  and  mucus  escapes  from  the  incision. 
A  tracheal  dilator  should  next  be  introduced  and  the 
trachea  cleared  of  membrane,  if  it  is  present  in  the  region 
of  the  wound,  with  a  feather  or  with  forceps.  The  tra- 
cheotomy-tube is  next  introduced,  and  is  secured  in  posi- 
tion by  tapes  tied  around  the  neck. 

If  respiration  has  ceased,  artificial  respiration  should  be 
resorted  to,  or  the  use  of  a  tube  attached  to  a  bellows,  or 
Fell's  apparatus;  these  efforts  should  be  continued  for  at 
least  fifteen  minutes,  for  I  have  seen  resuscitation  take 
place  in  patients  who  were  apparently  dead  by  a  persistent 
employment  of  artificial  respiration.  * 

Laryngotomy. — In  this  operation  an  opening  is  made 
into  the  air-passages  through  the  crico-thyroid  membrane. 
It  is  a  simple  operation,  and  one  which  is  practically  free 
from  risk,  and  can,  therefore,  be  performed  much  more 
rapidly  and  safely  in  urgent  cases  than  tracheotomy. 

The  patient  being  placed  in  the  recumbent  posture,  with 
the  shoulders  slightly  elevated  and  the  head  thrown  back, 
to  make  the  neck  as  prominent  as  possible,  the  surgeon 
feels  for  the  prominence  of  the  thyroid  cartilage,  and 
steadying  the  larynx  between  the  finger  and  thumb  of  the 
left  hand,  he  makes  an  incision  in  the  median  line  over 
the  centre  of  the  thyroid  cartilage  and  extending  down- 
ward for  an  inch  or  an  inch  and  a  half.  The  skin  and 
superficial  fascia  being  divided,  the  fascia  between  the 
sterno-hyoid  muscles  and  the  areolar  tissue  is  exposed  and 
divided,  and  the  crico-thyroid  membrane  is  exposed.  The 
knife  is  then  passed  transversely  through  the  membrane 
into  the  larynx,  care  being  taken  that  both  that  membrane 
and  the  mucous  membrane  which  covers  its  inner  surface 
are  divided  at  the  same  time.  As  soon  as  the  knife  enters 
the  cavity  of  the  larynx  blood  and  mucus  will  be  forcibly 
expelled. 

The  wound  should  be  carefully  enlarged  and  a  tube 
introduced,  which  differs  from  the  ordinary  tracheotomy- 
tube  in  being  slightly  flattened  ;  this  is  secured  in  position 
by  tapes  tied  around  the  neck,  as  in  the  case  of  the  ordi- 
nary tracheal  tube.     The  only  bleeding:  which  is  likelv  to 


Hi 


578  INTUBATION  OF  THE  LARYNX. 

occur  is  from  the  crico-thyroid  arteries  or  veins,  and  if  these 
cannot  be  avoided,  and  are  divided  in  the  operation,  they 
should  be  temporarily  secured  by  haemostatic  forceps  or 
ligated  ;  if  the  case  is  not  extremely  urgent,  all  bleeding 
should  be  arrested  before  the  crico-thyroid  membrane  is 
incised. 

Laryngo -tracheotomy. — This  operation  consists  in 
making  an  incision  into  the  air-passages  by  dividing  one 
or  two  of  the  upper  rings  of  the  trachea,  the  crico-tracheal 
membrane,  the  cricoid  cartilage,  and  the  crico-thyroid 
membrane.  This  operation  is  employed  in  cases  where, 
from  the  age  of  the  patient,  the  crico-thyroid  space  is  too 
small  to  admit  of  a  sufficient  opening,  or  in  those  in  which, 
for  any  reason,  the  surgeon  does  not  deem  it  advisable  to 
attempt  to  open  the  trachea  lower  down.  The  incision  in 
the  skin  and  superficial  fascia  of  the  neck  is  made  in  the 
same  manner  as  in  the  operation  of  laryngotomy,  but  is 
carried  a  little  further  downward.  It  may  be  necessary 
to  displace  the  isthmus  of  the  thyroid  gland  downward  to 
expose  the  upper  portion  of  the  trachea,  and  when  the 
trachea  is  exposed  the  incision  should  be  made  through 
this  and  the  cricoid  cartilage  from  below  upward.  A 
tracheotomy-tube  is  introduced  through  the  wound  and 
secured  by  tapes  tied  around  the  neck. 


INTUBATION  OF  THE  LARYNX. 

This  procedure,  at  the  present  time,  is  widely  employed 
as  a  substitute  for  tracheotomy  in  the  treatment  of  dyspnoea 
due  to  inflammatory  affections  of  the  larynx  or  trachea,  or 
stenosis  of  the  larynx  ;  it  consists  in  the  introduction  of  a 
metallic  or  hard-rubber  tube  into  the  larynx,  which  is 
allowed  to  remain  in  place  for  a  few  days.  This  oper- 
ation has  been  reintroduced  to  the  profession  by  the  late 
Dr.  O'Dwyer,  of  New  York,  who  devised  a  set  of  in- 
genious instruments  for  the  purpose  of  laryngeal  intu- 
bation. 

The  instruments  required  are  a  mouth-gag  (Fig.  485), 


INTUBATION  OF  THE  LARYNX. 


579 


Fig.  485. 


Mouth-gag. 
Fig.  486 


Intubation-tube  and  introducer. 
Fig.  487. 


Intubation-tube  extractor. 


with  which  the  jaws  are  separated  and  held  open  ;  an  in- 
strument for  the  introduction  of  the  tube,  which  is  fastened 


580 


INTUBATION  OF  THE  LARYNX. 


Fig.  488. 


■ 


3-*- 


f I 


Scale  of  intuba- 
tion-tubes. 


to  the  obturator,  which  fills  the  cavity  of  the  tube  (Fig. 
486);  and  an  instrument  for  extracting  the 
tube  after  it  has  been  placed  in  the  larynx 
(Fig.  487).  The  tubes  are  of  metal  or  hard 
rubber,  and  have  a  collar  which  rests  upon 
the  false  cords,  and  bulge  slightly  toward  their 
middle  and  again  taper  toward  their  lower 
extremity  ;  at  the  collar  of  the  tube  there  is  a 
perforation  through  which  a  strand  of  silk  is 
passed  which  is  made  into  a  loop  ;  this  is  used 
to  enable  the  operator  to  remove  the  tube  if 
on  its  introduction  it  is  found  to  have  passed 
into  the  oesophagus  instead  of  the  larynx, 
and  is  also  useful  in  removing  the  tube  if  it 
becomes  occluded  with  membrane  while  in  the 
larynx.  The  intubation  set  now  in  common 
use  is  provided  with  a  scale  of  seven  tubes, 
ranging  in  size  from  such  as  are  suited  for  a 
child  of  one  year  or  less  up  to  the  age  of 
twelve  or  fourteen  years  (Fig.  488).  Special 
tubes  are  required  for  intubation  in  adults. 

Operation  of  Intubation  of  the  Larynx. — In  perform- 
ing the  operation  of  intubation,  the  child  is  placed  upon 
the  lap  of  the  nurse  or  assistant,  wrapped  in  a  blanket, 
and  the  arms  secured  by  the  nurse  holding  the  elbows 
so  as  not  to  interfere  with  the  respiratory  movements. 
The  patient's  head  is  next  held  by  an  assistant.  The 
position  of  the  head,  neck,  and  body  should  be  as  if  the 
child  were  hung  from  the  top  of  the  head,  and  this  posi- 
tion should  be  maintained  during  the  insertion  of  the 
tube.  The  mouth-gag  is  next  inserted  upon  the  left  side, 
and  the  blades  dilated  so  as  to  open  the  jaws  widely,  and 
as  the  gag  is  self-retaining,  this  position  is  easily  main- 
tained. The  jaws  being  thus  held  open,  the  operator, 
sitting  on  a  chair  facing  the  patient  (Fig.  489),  next  intro- 
duces the  index  finger  of  the  left  hand,  protected  by  a 
strip  of  adhesive  plaster  or  a  metal  shield,  into  the  mouth 
and  passes  it  over  the  tongue  until  he  feels  the  epiglottis. 
The  introducing-instrument,  to  which  the  tube  is  attached, 


INTUBATION  OF  THE  LARYNX. 


581 


is  held  in  the  right  hand,  and  introduced  into  the  mouth, 
after  observing  that  the  silken  loop  is  free;  it  is  swept 
over  the  tongue  and  passed  down  until  it  touches  the  epi- 
glottis j  this  is  hooked  up  by  the  index  linger  of  the  left 
hand  and  the  tube  passed  into  the  larynx;  the  index 
finger  of  the  left  hand  is  then  transferred  to  the  edge  of  the 
tube,  and  by  pressing  upon  the  trigger  of  the  instrument 

Fig.  489. 


Intubation  of  the  larynx. 

with  the  thumb  of  the  right  hand  the  obturator  is  detached 
and  the  instrument  is  withdrawn,  and  before  removing  the 
finger  it  is  well  to  place  it  upon  the  head  of  the  tube  and 
to  sink  it  well  into  the  larynx.  As  soon  as  the  obturator 
is  removed,  there  is  usually  a  violent  expiratory  effort, 
which  is  accompanied  by  a  gush  of  mucus,  mucopurulent 
matter,  or  membrane  fn  >m  the  tube,  and  after  this  escapes 


582  INTUBATION  OF  THE  IARYNX. 

the  breathing  is  usually  satisfactorily  established.  If  the 
operator  has  passed  the  tube  into  the  oesophagus  and  has 
detached  it  from  the  introducing-instrument,  no  improve- 
ment in  the  respiration  takes  place ;  it  should  then  be 
withdrawn  by  the  silk  loop  and  attached  to  the  tube,  and 
another  attempt  made  to  introduce  it  into  the  larynx. 

The  mistake,  which  inexperienced  operators  make  in 
attempting  to  introduce  the  tube  is  in  not  hugging  the 
posterior  surface  of  the  tongue  closely,  thereby  passing 
the  tube  over  the  epiglottis  into  the  oesophagus. 

The  silken  loop  may  be  brought  out  at  one  side  of  the 
mouth  and  adjusted  around  the  ear  or  fastened  to  the 
side  of  the  face  by  strips  of  adhesive  plaster  for  a  few 
hours,  so  that  by  drawing  upon  it  the  nurse  or  attendant 
can  withdraw  the  tube  instantly  if  it  should  become 
obstructed  with  membrane ;  or,  if  it  is  coughed  up,  by 
this  means  it  may  be  withdrawn  from  the  oesophagus  if 
it  has  not  been  expelled  from  the  mouth.  Some  operators 
keep  the  loop  attached  to  the  tube  during  the  time  it  is 
retained  in  the  larynx.  I  prefer  to  remove  it  after  the 
tube  is  securely  placed  in  the  larynx,  and  to  withdraw  the 
tube  by  means  of  the  extracting-instrument  when  required. 
The  tube  should  be  removed  at  the  end  of  the  second  or 
third  day,  and  if  the  child  can  breathe  comfortably  for  an 
hour  or  two  it  need  not  be  reintroduced;  if,  however,  the 
dyspnoea  returns,  it  should  be  reintroduced,  and  allowed 
to  remain  one  or  two  days  longer ;  several  attempts  may 
have  to  be  made  before  the  tube  can  be  permanently 
removed ;  it  is  usually  dispensed  with  from  the  third  to 
the  eighth  day. 

The  most  serious  complication  which  is  apt  to  occur 
during  the  introduction  of  the  intubation-tube  is  the 
detachment  and  pushing  of  a  mass  of  membrane  in  front 
of  the  tube  into  the  trachea;  if  the  mass  is  too  large  to 
be  expelled  through  the  tube,  the  breathing  is  suddenly 
arrested.  The  tube  should  be  removed  at  once,  and  if  the 
mass  of  membrane  does  not  escape  with  the  expiratory 
efforts  of  the  patient,  the  trachea  should  be  rapidly  opened 
as  the  only  means  of  re-establishing  the  respiratory  func- 


INTUBATION  OF  THE  LARYNX. 


583 


tion.  So  much  do  I  dread  this  accident,  which  has 
occurred  in  a  few  cases,  that  J  never  introduce  the  intuba- 
tion-tube without  having  at  hand  the  necessary  instru- 
ments to  do  a  tracheotomy  if  it  should  be  suddenly 
required,  and,  if  possible,  obtain  the  consent  of  the 
parents  or  friends  to  perform  tracheotomy  if  it  should  be 
indicated. 

Feeding  after  Intubation. — One  of  the  greatest  difficul- 
ties after  intubation  of  the  larnyx  is  the  satisfactory  feed- 
ing of  the  patient;  liquids,  as  a  rule,  are  not  swallowed 

Fig.  490. 


Feeding  a  case  of  intubation  of  the  larynx. 

well,  a  portion  escaping  into  the  tube,  causing  coughing 
and  difficulty  in  breathing.  The  diet  I  usually  prefer  is 
semisolid,  such  as  corn-starch,  soft-boiled  eggs,  and  mush ; 


584  OPERATIONS   UPON  THE  KIDNEY. 

and  if  these  are  not  well  swallowed,  it  may  be  necessary 
to  resort  to  nutritions  enemata  or  the  use  of  a  stomach- 
tube  to  introduce  food.  Some  patients  swallow  liquids  and 
semisolids  quite  well  if  the  head  is  placed  a  little  lower 
than  the  body  during  the  act  of  deglutition  (Fig.  490). 


OPERATIONS  UPON  THE  KIDNEY. 

Nephrotomy. — In  this  operation  an  incision  is  made 
into  the  kidney.  The  incision  for  exposure  of  the  kidney 
is  four  inches  in  length,  and  should  be  made  from  a  point 
two  and  a  half  inches  from  the  spine,  half  an  inch  below 
the  last  rib  and  parallel  with  it.  The  latissimus  dorsi, 
external  and  internal  oblique,  and  transversalis  muscles 
are  divided,  and  the  lumbar  fascia  is  opened,  exposing  the 
perinephric  fat ;  the  kidney  is  then  reached  by  displacing 
this. 

Lumbar  Nephrectomy. — The  incision  is  the  same  as 
for  nephrotomy ;  the  wound  may  be  enlarged  by  another 
incision  at  right  angles  to  the  first  if  more  space  is  required. 
After  the  kidney  is  exposed,  its  capsule  is  incised  and  the 
finger  passed  around  the  organ  to  separate  it  freely  from 
the  capsule.  When  the  ureter  is  recognized,  it  is  brought 
into  view,  ligated,  and  cut  off.  The  pedicle  containing 
the  vessels  is  next  tied,  and  divided  in  advance  of  the  lig- 
ature with  scissors,  and  the  kidney  removed. 

Abdominal  Nephrectomy.— To  reach  the  kidney  by 
abdominal  incision,  an  incision  four  inches  long  is  made 
at  the  outer  border  of  the  rectus  muscle  ;  the  abdomen 
is  opened  and  the  viscera  turned  aside ;  the  kidney  is 
exposed  and  the  capsule  opened  ;  the  ureter  and  the  renal 
vessels  are  ligated  and  divided,  and  the  organ  removed ; 
a  drainage-tube  may  be  introduced  or  the  wound  in  the 
abdominal  walls  may  be  closed  without  drainage. 

Nephrorrhaphy.— Nephrorrhaphy  is  an  operation  in 
which  the  kidney  is  exposed  through  a  similar  incision  to 
that  for  nephrotomy,  with  the  object  of  suturing  a  mov- 
able kidney  fast  in  its  normal  position  in  the  back;  when 


OPERATIONS   UPON  THE  COLON 


585 


the  kidney  has  been  reached,  a  number  of  sutures  are 
introduced  into  the  capsule  of  the  kidney,  and  secured  to 

the  fibrous  and  muscular  tissue  of  the  incision.  Many 
surgeons  prefer  to  omit  the  introduction  of  sutures,  and 
simply  scarify  the  capsule  of  the  kidney  or  dissect  off  a 

portion  of  the  capsule,  and  then  pack  the  wound  with 
strips  of  gauze  and  allow  it  to  heal  by  granulation. 

Other  methods  of  fixing  a  movable  kidney  consist  in 
dissecting  a  flap  from  the  capsule  of  the  kidney  and  sutur- 
ing it  to  the  muscular  tissues  of  the  external  wound  before 
closing  the  wound.  Some  surgeons  prefer  to  introduce  no 
sutures,  but  to  pass  two  gauze  loops  around  the  kidney  at 
different  points,  and  pack  the  wound  with  gauze.  The 
loops  are  not  removed  for  a  few  days,  and  the  wound  is 
allowed  to  heal  by  granulation. 


OPERATIONS  UPON  THE  COLON. 

Lumbar  Colostomy. — In  performing  lumbar  colotomy, 
or  colostomy,  on  the  left  side,  the  patient  should  be  placed 


Fig.  491. 


Incision  in  lumbar  colostomy — dotted  line  shows  the  situation  of  the  colon. 

('Bryant.) 

upon  the  right  side,  and  a  pillow  placed  under  the  loin  to 
make  the  left  side  more  prominent.  An  incision  four 
inches  in  length  is  made  midway  between  the  last  rib  and 


586 


OPERATIONS   UPON  THE  COLON. 


the  crest  of  the  ilium,  the  centre  of  the  incision  corre- 
sponding to  a  point  midway  between  the  anterior  superior 
and  posterior  superior  spines  of  the  ilium  ;  the  tissues  are 
divided  to  the  full  extent  of  the  wound  until  the  lumbar 
fascia  and  edge  of  the  quadratus  lumborum  muscle  have 
been  reached  ;  the  former  being  cut  through  and  the  edge 
of  the  muscle  divided,  the  bowel  is  exposed,  when  it  is 
brought  to  the  surface  and  fastened  by  sutures  to  the  skin 
and  subjacent  tissues,  and  opened. 

Inguinal  Colostomy. — In  this  operation  an  incision 
three  inches  in  length  is  made  on  the  left  side  parallel  to 
and  one  inch  above  Poupart's  ligament,  with  its  centre  on 
a  level  with  the  anterior  superior  spine  of  the  ilium,  or  a 
little  lower;  or,  as  practised  by  Ball,  the  colon  may  be 
exposed  by  an  incision  two  and  a  half  inches  in  length, 
following  the  line  of  the  linea  semilunaris,  stopping  just 
short  of  Poupart's  ligament ;  the  tissues  are  divided  layer 
by  layer  and  the  peritoneum  opened  ;  the  skin  and  parietal 
peritoneum  may  be  united  by  a  few  sutures ;  the  gut  is 
then  brought  out  at  the  wound,  fastened  to  its  margins  by 
fine  sutures,  and  opened. 

Maydl's  Operation. — In  this  operation  the  colon  is 
exposed  as  in  the  preceding  operation,  and  then  drawn  out 


Fig.  492. 


Colon  held  in  wound  by  glass  rod.     (Pilcher.) 

of  the  wound  until  its  mesenteric  attachment  is  on  a  level 
with  the  external  incision.  A  sterilized  glass  rod  or  piece 
of  catheter,  or  a  roll  of  gauze  three  inches  in  length,  is 


REMOVAL   OF  THE  APPENDIX   VERMIFORMIS.    587 

slipped  through  a  slit  in  the  mesocolon  close  to  the  gut. 
This  holds  the  intestine  in  the  wound  and  prevents  its 
return  to  the  abdominal  cavity  until  adhesions  have 
formed.  The  two  limbs  of  the  flexure  of  the  gut  exposed 
in  the  wound  should  be  united  by  sutures  beneath  the 
rod.  If  the  gut  is  to  be  opened  immediately,  it  should 
be  stitched  to  the  parietal  peritoneum  of  the  abdominal 
incision.  If  the  opening  of  the  bowel  can  be  postponed 
for  twenty-four  or  forty-eight  hours,  the  introduction  of 
sutures  is  not  required.  The  bowel  may  be  opened  by  a 
transverse  incision  with  a  knife,  or  by  the  thermo-cautery, 
to  avoid  bleeding. 


REMOVAL  OF  THE  APPENDIX  VERMIFORMIS. 

To  expose  the  appendix,  an  incision  three  to  four  inches 
in  length  is  made  at  the  outer  border  of  the  right  rectus 

Fig.  493. 


Method  of  burying  the  stump  of  the  appendix.     (Richardson.) 

muscle,  with  its  centre  on  a  line  drawn  between  the  um- 
bilicus and  the  anterior  superior  spine  of  the  ilium  ;  the 


588  LITHOTOMY. 

tissues  are  divided  layer  by  layer  and  the  peritoneum 
picked  up  and  opened  ;  the  anterior  longitudinal  band  is 
recognized  and  traced  down  to  its  origin  at  the  appendix. 
When  the  appendix  is  found,  the  meso-appendix  is  ligated 
and  the  appendix  removed.  In  removing  the  appendix, 
a  circular  incision  may  be  made  around  it  near  its  base 
and  the  cuff  turned  back ;  the  body  of  the  appendix  is 
then  ligated  and  cut  off  in  advance  of  the  ligature,  and 
the  turned-back  cuff  brought  forward  and  united  by  fine 
silk  or  catgut  sutures.  The  appendix  may  also  be  ligated 
and  cut  off  close  to  the  gut,  or  removed  by  cutting  it  off 
close  to  the  gut  and  then  inverting  its  stump  into  the 
colon,  and  subsequently  suturing  the  wTalls  of  the  colon 
together  over  the  position  of  the  stump  of  the  appendix 
by  a  few  Lembert  sutures  (Fig.  493).  In  cases  of  appen- 
dicitis with  abscess,  simple  ligation  of  the  appendix  before 
removal  is  usually  the  only  method  that  can  be  employed. 
McBurney's  Operation.  —When  the  appendix  is  re- 
moved in  cases  of  chronic  appendicitis,  this  procedure  may 
be  employed  with  advantage.  It  consists  in  making  the 
ordinary  incision,  and  when  the  external  oblique  muscle 
is  exposed,  its  fibres  are  separated  in  the  direction  of  their 
length ;  the  edges  of  the  wround  are  next  dilated,  and 
the  fibres  of  the  internal  oblique  and  transversalis  muscles 
separated  in  the  same  manner.  After  the  operation  is 
completed,  the  fibres  of  the  muscles  may  be  sutured,  and, 
as  they  cross  each  other,  firm  support  is  given  to  the 
abdominal  contents,  and  there  is  little  likelihood  of  a 
hernia  forming  at  the  site  of  the  incision. 

LITHOTOMY. 

Left  Lateral  Lithotomy. — In  performing  this  opera- 
tion, the  patient  is  placed  upon  his  back,  the  hands  and 
feet  are  secured  together,  and  the  bladder  is  injected  with 
a  few  ounces  of  boric  acid  solution.  A  grooved  staff  is 
introduced  into  the  bladder,  the  operator  first  passing  one 
finger  into  the  rectum  to  locate  the  position  of  the  staff 
as  regards  the  prostate.     An  incision  is  then  made  a  little 


SUPRAPUBIC  LITHOTOMY. 


589 


to  the  left  of  the  raphe  of  the  perineum,  a  quarter  to  half 
an  inch  in  front  of  the  anus,  and  is  carried  downward  by 
careful  strokes  of  the  knife  until  the  staff  is  reached,  about 
half  an  inch  in  front  of  the  prostate.  When  the  point  of 
the  knife  enters  the  groove  in  the  staff,  it  is  pushed  back- 
ward, keeping  it  well  in  the  groove  until  the  prostate  is 
incised  and  a  gush  of  fluid  escapes  along  the  knife,  when 
it  is  removed  and  the  index  finger  introduced  and  the 
stone  located ;  lithotomy  forceps  are  next  introduced  and 
the  stone  removed  (Fig.  494). 

Fig.  494. 


Deep  incision  in  lateral  lithotomy.     (Fergusson.) 

Suprapubic  Lithotomy. — The  operation   of  opening 

the  bladder  above  the   pubes  may  be  performed  for  the 

removal  of  stone  from  the  bladder,  for  the  extirpation  of 

growths,  or  for  drainage  of  the  bladder.     The  hair  on  the 

pubes  should  be  shaved  off,  the  bladder  injected  with  a  few 

ounces  of  saline  solution,  and  a  rubber  band  tied  around 

the  penis ;  a  small  rubber  bag  is  then  introduced  into  the 

rectum  empty  and  filled  with  air  or  water.      An  incision 

two  or  three  inches  in  length  is  made  in  the  median  line 

• 
of  the  abdomen  just  above  the  symphysis  pubis,  and  is 

deepened  gradually  until  the  deep  fascia  is  reached  ;  this 


590 


CIRCUMCISION. 


is  divided,  exposing  the  prevesical  fat;  when  this  is  dis- 
placed, the  wall  of  the  bladder  is  exposed  to  view.  A 
tenaculum  is  next  introduced  into  the  highest  part  of  the 
vesical  wall,  to  fix  it,  and  a  knife  thrust  through  the  wall 
of  the  bladder,  the  incision  being  carried  downward  about 
an  inch.  After  the  bladder  is  opened,  forceps  are  intro- 
duced and  the  calculus  removed.  If  opened  for  calculus 
and  the  bladder-walls  are  healthy,  the  wound  may  be 
sutured  with  stitches  which  do  not  pass  through  the 
mucous  coat.  The  external  wound  is  then  sutured  and 
the  bladder  drained  by  a  soft  catheter  passed  by  the  ure- 
thra. If  the  bladder-walls  are  much  diseased,  the  wound 
is  left  open  and  drainage  effected  by  a  rubber  tube  passed 
through  the  suprapubic  wound  into  the  bladder. 

CIRCUMCISION. 

Circumcision  is  performed  by  drawing  the  prepuce  for- 
ward and  then  enclosing  it  in  a  pair  of  clamp-forceps 

Fig.  495. 


Circumcision. 


placed  obliquely  just  in  front  of  the  glans  (Fig.  495).    The 
prepuce  is  next  divided  with  a  straight  bistoury,  and  the 


CHOLEl  'YSTOTOMY.  591 

forceps  removed,  when  the  .skin  and  m neons  membrane 
retract.  The  mucous  membrane,  if  adherent,  is  dissected 
loose  from  the  glans ;  if  redundant,  it  is  trimmed  with 
scissors  to  make  it  correspond  to  the  line  of  skin  incision ; 
the  cut  edge  of  the  mucous  membrane  is  next  fastened  to 
the  cut  edge  of  the  skin  by  a  few  sutures  of  silk  or  catffiit. 

REMOVAL  OF  THE  TESTICLE. 

In  removing  the  testicle,  a  longitudinal  incision  is  made 
over  the  upper  part  of  the  gland  and  spermatic  cord  and 
the  envelopes  of  the  testicle  and  cord  divided ;  the  cord  is 
then  exposed  and  ligated,  or  the  different  components  of 
the  cord  may  be  separated  and  tied  independently  ;  the 
cord  is  divided  in  advance  of  the  ligatures  and  the  gland 
removed. 

OPERATION  FOR  VARICOCELE. 

In  operating  for  varicocele,  the  dilated  veins  of  the 
spermatic  cord  may  be  ligated  by  a  subcutaneous  ligature 
passed  around  the  cord,  care  being  taken  that  the  vas 
deferens  is  not  included.  Or  the  veins  of  the  cord  may 
be  exposed  by  an  incision  an  inch  and  a  half  or  two  inches 
in  length,  at  the  upper  part  of  the  scrotum,  over  the  cord. 
The  veins  being  exposed,  the  larger  portion  of  them  are 
isolated,  and  two  ligatures  are  passed  around  the  mass  of 
veins  about  an  inch  or  an  inch  and  a  half  apart  and  firmly 
tied.  The  portion  of  the  cord  between  the  ligatures  is 
excised  and  the  divided  ends  of  the  veins  brought  in  con- 
tact by  tying  together  the  ends  of  the  ligatures  upon  the 
proximal  and  distal  ends  of  the  veins ;  the  wound  is  then 
closed  with  sutures. 

CHOLECYSTOTOMY. 

An  incision  three  or  four  inches  in  length  is  made  verti- 
cally downward  from  the  lower  border  of  the  liver  opposite 
the  tip  of  the  lower  border  of  the  tenth  rib  ;  the  tissues  are 
divided   and    the   peritoneum  opened.     The  gall-bladder 


592  GASTROSTOMY. 

is  then  exposed,  opened,  and  sutured  to  the  subcutaneous 
tissues  of  the  external  wound.  If  the  gall-duct  is  to  be 
explored,  this  is  done  with  the  finger  from  without  or  by  a 
probe  introduced  into  it  through  the  gall-bladder.  After 
the  gall-bladder  has  been  opened  and  the  stone  removed, 
it  may  be  closed  by  sutures ;  or  it  may  be  left  open,  and 
a  drainage-tube  or  gauze  drainage  introduced. 

EXTERNAL  (ESOPHAGOTOMY. 

A  sound  is  passed  through  the  mouth  into  the  oesopha- 
gus until  its  point  comes  in  contact  with  the  stricture  of 
the  ceosphagus  or  the  foreign  body  which  requires  removal. 
An  incision  is  then  made  from  a  point  one  inch  above  the 
sternum  to  the  line  of  the  upper  border  of  the  thyroid 
cartilage  on  the  inner  side  of  the  sterno-cleido-mastoid 
muscle;  the  anterior  jugular  vein  is  displaced,  the  fascia  is 
divided,  the  omohyoid  muscle  is  drawn  aside,  the  sterno- 
mastoid  muscle  and  the  vessels  are  drawn  to  the  outer  side 
with  blunt  hooks,  and  by  dissecting  down  with  the  finger 
the  oesophagus  is  exposed;  the  sound  which  has  been 
passed  into  the  oesophagus  may  easily  be  felt,  and  the 
oesophagus  incised  upon  the  point  of  this  sound.  If  a 
permanent  opening  is  desired,  the  edges  of  the  oesophagus 
are  sutured  to  the  skin. 

GASTROSTOMY. 

An  incision  one  and  a  half  to  two  inches  in  length  is 
made  parallel  to  and  a  finger's  breadth  from  the  border  of 
the  left  costal  cartilage,  ending  opposite  the  border  of  the 
tenth  rib  ;  the  tissues  are  divided  layer  by  layer  until  the 
peritoneum  is  reached  (Fig.  496).  The  latter  membrane 
should  be  pinched  up  and  opened  ;  the  stomach  is  recog- 
nized and  brought  out  of  the  wound ;  the  parietal  perito- 
neum is  stitched  to  the  skin  around  the  wound,  and  a  fold 
of  the  unopened  stomach  is  brought  out  of  the  wound 
and  sutured  to  the  parietal  peritoneum  and  the  abdominal 
wall.     The  opening  of  the  stomach  is  delayed  for  twenty- 


GASTROSTOMY. 


593 


four  hours,  if  possible,  to  allow  of  the  formation  of  adhe- 
sions between  its  surface  and  the  parietal  peritoneum. 


Fk;.  4%. 


v 
Anatomical  relations  of  the  stomach.    (Stimson.) 

Fig.  497. 


Ssabanajew-Frank  method  ;  first  stage.     (Richakdson.) 

Ssabanajew-Frank  Method. — A  curved  incision,  three  or 
four  inches  in  length,  is  made  at  the  margin  of  the  costal 

38 


5CJ4 


GASTROSTOMY. 
Fig.  498. 


.  i 


Ssabanajew- Frank  method  ;  second  stage.    (Richardson.) 
Fig.  499. 


jr       JMMi 


Witzel  method  of  infolding  the  tube.     (Richardson.) 


GASTROSTOMY. 


595 


cartilages  of  the  left  side,  and  the  surface  of  the  stomach 
is  exposed.  A  cone  of  the  stomach-wall  is  then  grasped 
with  forceps,  pulled  out  of  the  wound  (Fig.  497),  and  passed 
under  a  bridge  of  skin  and  connective  tissue  and  made  to 
project  from  a  separate  wound  made  about  one  and  a  half 
inches  above  the  original  wound  (Fig.  498).  The  wall  of 
the  stomach  is  fastened  in  the  original  wound  by  sutures 

Fig.  500. 


Witzel  method ;  tube  infolded  and  sutures  introduced  to  close  the  wound. 

(Richardson.) 

and  the  wound  closed,  the  projecting  portion  of  the  stom- 
ach in  the  upper  wound  being  secured  by  sutures.  The 
stomach  may  be  opened  at  any  time. 

Witzel's  Method. — This  method  of  gastrostomy  also  pre- 
vents leakage,  and  is  accomplished  by  making  an  incision 
and  exposing  the  wall  of  the  stomach.  A  small  incision 
is  made  in  the  wall  of  the  stomach  and  a  rubber  tube  or 
catheter  introduced ;  the  portion  of  the  tube  in  contact 
with  the  stomach  external  to  the  wound  is  then  infolded 


596 


PYLOROPLASTY. 


by  peritoneal  approximation,  as  shown  in  Fig.  499.  The 
stomach  is  then  stitched  to  the  abdominal  wall  and  the 
external  wound  closed  (Fig.  500).  The  tube  should  not 
be  removed  for  a  week ;  feeding  may  be  begun  through 
the  tube  immediately.  Contraction  of  the  fistula  may  be 
prevented  by  the  occasional  introduction  of  the  tube  or 
catheter. 

PYLOROPLASTY. 

This  operation  is  practised  in  non-malignant  strictures 
of  the  pylorus.     The  pyloric  extremity  of  the  stomach  is 

Fig.  501. 


Incision  in  pyloroplasty.    (Richardson.) 
Fig.  502. 


Incision  closed  transversely  by  sutures.    (Richardson.) 


PYLORECTOMY  AND  GASTRO-DUODENOSTOMY.    597 

exposed  by  a  median  incision,  and  a  longitudinal  incision 
is  made  through  the  anterior  surface  of  the  constricted 
pylorus  (Fig.  501),  and  the  incision  closed  by  sutures 
introduced  transversely,  as  shown  in  Fig.  502. 


PYLORECTOMY  AND  GASTRO-DUODENOSTOMY. 


This  operation  is  practised  in  malignant  strictures  of 
the  pylorus.  It  consists  in  exposing  the  stomach  and 
duodenum   by   a  median  abdominal  incision ;  the    upper 


Fig.  503. 


Lines  of  incision  for  excision  of  pylorus.    (Richardson.) 

portion  of  the  duodenum  and  the  stomach  are  drawn 
through  the  incision,  and  resection  of  the  diseased  portion 
accomplished  (Fig.  503).  The  opening  in  the  stomach 
being  much  larger  than  that  resulting  from  resection  of 
the  duodenum,  the  wound  in  the  stomach  should  be  par- 
tially closed  by  Lembert  sutures  (Fig.  504)  ;  and  when  it 
has  been  reduced  to  a  proper  size  to  fit  the  free  end  of  the 
duodenum,  they  are  fitted  together  and  held  in  position 
by  the  introduction  of  a  circular  row  of  closely  applied 
Lembert  sutures  (Fig.  505). 


598    PYLORECTOMY  AND   GASTRO-DUODENOSTOMY. 

Fig.  504. 


Pylorus  excised  and  opening  into  the  stomach  partially  closed.   (Richardson.) 

Fig.  505. 


Gastro-duodenostomy  completed.    (Richardson.) 


GASTRO-ENTKllOSTOMY. 


599 


GASTROENTEROSTOMY. 

This  operation  may  bo  combined  with  pylorectomy,  or 
in  cases  where  it  is  inadvisable  to  resect  the  pylorus,  a 
lateral  anastomosis  between  the  stomach  and  a  coil  of 
small  intestine  near  the  stomach  may  be  made,  so  that  the 
contents  of  the  stomach  may  find  their  way  into  the  intes- 
tine through  this  artificial  opening.     "Where  resection  of 

Fig.  506. 


Pylorectomy  and  gastroenterostomy.    (Richardson.) 

the  pylorus  is  combined  with  gastroenterostomy,  the 
method  of  closing  the  duodenum  and  stomach  and  of  anas- 
tomosis between  the  intestine  and  the  stomach  are  shown 
in  Ficr.  506. 

OSTEOTOMY. 

This  operation  consists  in  dividing  the  bones  with  a 
saw  or  osteotome,  and  is  employed  to  correct  deformities 
of  the  bones  or  joints. 


600 


OSTEOTOMY. 


The  instruments  employed  are  a  saw  with  short  cutting 
surface,  Adams's  saw  (Fig.  507),  or  osteotomes  (Fig.  508) ; 


Fig.  507. 


Adams's  saw. 


a  heavy  mallet  is  used  to  drive  the  osteotome  through  the 
bone.  Osteotomy  is  often  employed  to  correct  deformi- 
ties of  the  hip  following  coxalgia,  and  here  the  femur  is 


Fig.  508. 


Macewen's  osteotome. 


divided  either  at  the  neck,  Adams's  operation,  or  just  below 
the  trochanters,  Gant's  operation. 

Osteotomy  of  the  Femur  below  the  Trochanters. — 
A  puncture  is  made  with  a  bistoury  on  the  outer  side  of 
the  femur  just  below  the  great  trochanter,  and  is  carried 
down  to  the  bone;  the  blade  of  the  saw  is  then  introduced 
and  the  femur  divided  from  before  backward.  The  femur 
may  also  be  divided  in  this  position  with  an  osteotome. 

Osteotomy  for  Knock-knee. — The  operation  employed 
to  correct  this  deformity  is  a  transverse  section  of  the 
femur  above  the  condyles  (Fig.  509).  In  the  operation 
of  supracondyloid  osteotomy  the  knee  is  flexed  and  sup- 
ported on  a  sand  bag.  A  longitudinal  incision  one  inch 
in  length  is  made  half  an  inch  anterior  to  the  tendon  of 
the  adductor  magnus  and  a  finger's  breadth  above  the 
internal  condyle;  the  knife  is  carried  down  to  the  bone, 
and  before  it  is  withdrawn  an  osteotome  is  introduced  and 
its  edge  turned  so  as  to  divide  the  bone  transversely.  The 
section   of  the  bone  is  accomplished  by  the  use  of  the 


OSTEOTOMY   FOR    BOWLEGS. 


60] 


osteotome  and  mallet.  After  the  bone  has  been  divided, 
the  deformity  is  corrected,  the  wound  closed,  and  the  limb 
put  up  in  a  plaster-of- Paris  dressing  in  the  corrected  posi- 
tion. 

Fig.  509. 


Til;?;-i?.i..^ 


A.  Epiphyseal  line.    C.  Liue  of  bone  section  in  supracondyloid  osteotomy. 

Osteotomy  for  Bowlegs. — To  correct  this  deformity, 
the  tibia  and  fibula  are  divided  at  the  point  of  greatest 
bowing  with  an  osteotome.  The  fibula  is  divided  first 
with  an  osteotome  entered  through  a  puncture  over  the 
fibula,  and  next  the  tibia  is  divided  in  the  same  manner. 
The  bones  being  divided,  the  deformity  is  corrected  and 
the  limb  put  up  in  a  plaster-of- Paris  dressing  in  the  cor- 
rected position.  Osteotomy  may  also  be  employed  to 
correct  deformities  in  other  bones,  or  for  the  deformity 
resulting  from  fractures  united  in  faulty  position. 


INDEX. 


4  BDOMEN,    many-tailed    band- 

A.     age  of,  31 

Abdominal  aorta,  ligation  of,  463 

nephrectomy,  584 
Abscess,  acute,  311 

aspiration  in,  313 

chronic,  313 

Hilton's  method  in,  311 

incision  of,  314 

injection  of,  313 

puncture  of,  313 

treatment  of,  311 

tuberculous,  313 
Absorbent  cotton,  167 
A.-C.-E.-mixture,  253 
Acetanilid,  134 
Acetate  of  aluminum,  134 
Acid,  boric,  135 

carbolic,  130 

salicylic,  135 
Acromial  end  of  clavicle,  disloca- 
tions of,  417 
Actinomyces,  122 
Actual  cautery,  189 
Acupressure,  303 
Acupuncture,  188 

needles,  189 
Acute  abscess,  311 
Adhesive  plaster,  169 
Adrenalin  chloride  in  hemorrhage, 

299 
Airol,  132 
AlkVs  inhaler,  244 
Ambulatory  treatment  of  fracture 
of  bones  of  leg,  400 
of  the  femur,  392 
Amputating  knive-.  4V2 

saws,  483 
Amputation  or  amputations.  4.7 

above  the  shoulder-joint,  506 


Amputation     or     amputations,    at 
ankle-joint,  514 

Pirogoff  s,  515 

Boux's,  517 

Svme's,  514 
of  arm,  499 

circular,  499 

modified  circular,  500 

transfixion  method  in,  499 
circular,  477 
details  of,  487 
at  the  elbow,  497 

circular,  498 

elliptical  method,  499 

flap  method,  497 
elliptical.  479 
of  fingers,  490 
of  foot,  507 

Choparts,  513 

Hancocks.  518 

Hey's,  513 

kisfranc"s,  512 

Tripier's,  518 
of  forearm,  496 

circular,  496 

modified  circular.  497 
of  hand,  490 
at  hip-joint,  527 

flap  method,  529 

modified  circular,  529 

transfixion  method,  528 

AVyeth's  method.  529 
instruments  for,  4^2 
at  knee-joint.  522 

Garden's.  523 

elliptical,  522 

flap  method,  522 

Gritti's.  524 
of  the  leg,  519 

circular,  519 

603 


604 


INDEX. 


Amputation  or  amputations,  of  the 
leg,  elliptical,  519 
flap  method,  519 
modified  circular,  519 
Sedillot's,  521 
Teale's,  520 
of  metacarpal  bones,  493 
of  metatarsal  bones,  510 
methods  of,  477 
modified  circular,  479 
osteoplastic.  Bier's,  481 

Mikulicz's,  518 
oval,  479 

periosteal  flaps  in,  482 
redressing  of,  488 
at  shoulder-joint,  501 
Dupuytren's,  504 
Larrey's,  503 
Lisfranc's,  505 
Spence's,  505 
Wyeth's  pins  in,  502 
subastragaloid,  514 
tarso-metatarsal,  510 
Teale's,  480 
of  the  thigh,  525 
flap  method,  526 
modified  circular,  525 
transfixion  method,  526 
trochanters  of  femur,  527 
of  toes,  507 
tourniquets  in,  486 
by  transfixion,  478 
at  the  wrist,  495 
circular,  495 
flap  method,  495,  496 
Anaesthesia  from  chloride  of  ethyl, 
233 
from  cocaine,  234 
from  cold,  233 
from  eucaine,  236 
general,  233,  239 
from  holocaine,  236 
from  hypnotism,  255 
infiltration,  236 
local,  232,  233 
neural,  237 

from  rapid  respiration,  234 
regional,  237 

from    spinal   arachnoidal   injec- 
tion, 238 
Anaesthetic  or  anaesthetics,  232 


Anaesthetic    or    anaesthetics,    after- 
effects of,  254 
choice  of,  239 

in  examination  of  fractures,  338 
mixture,  Schleich's,  253 
Anastomosis  -forceps,  286 
intestinal,  280 
end-to-end,  285 
lateral,  283 
Senn's  283 
Aneurism  needle,  302,  447 
Ankle,  dislocations  of,  438 
Ankle-joint,  amputation  at,  514 
excision  of,  548 
strapping  of,  176 
Anomalous  dislocations  of  the  hip, 

435 
Anterior  figure-of-eight  bandage  of 

chest,  69 
Antipyrin  in  hemorrhage,  299 
Antisepsis,  125 

theory  of,  123 
Antiseptic  method,  127 
operation, -details  of,  158 
poultice,  179 

treatment  of  infected  wounds,  164 
Antitoxin,  117 

injection  of,  215 
Antrum  of  Highmore,  trephining 

of,  556 
Aorta,  abdominal,  ligation  of,  463 
Appendicectomy,  587 

McBurney's,  588 
Appendix  vermiformis,  removal  of, 

587 
Approximation  sutures,  269 
Aqua  ammonia,    counter-irritation 

from,  186 
Aristol,  136 
Arm,  amputations  of,  499 

and  chest  bandage,  67 
Arterial    hemorrhage,    permanent 
control  of,  298 
temporary  control  of,  292 
transfusion,  199 
Arteries,  ligation  of,  445.  See  under 
each  artery, 
suture  of,  303 
wounded,  ligation  of,  304 
Arteriotomy,  198 
Artery  forceps,  301 


INDEX. 


605 


Arthrectomy  of  knee-joint,  547 

Artificial  respiration,  201 
direct  method,  202 
Howard's  method,  202 
Laborde's  method,  206 
Silvester's  method,  202 
Ascending  spica-bandage  of  groin, 

73 
Asepsis,  125 

agents  to  secure,  128 
theory  of,  123 
Aseptic  dressings,  improvised,  146 
methods  of,  149 
method,  127 
operation,  details  of,  157 

preparation  for  150 
treatment    of    infected    wounds, 
164 
Aspiration,  208 

in  abscess,  313 
Astragalus,  dislocation  of,  439 

excision  of,  549 
Auto-transfusion,  199 
Axillarv  artery,  ligation  of,  456 

BACILLUS    aerogenes    capsula- 
tus,  122 

anthracis,  121 

coli  communis,  119 

of  malignant  oedema,  121 

mallei,  120 

of  tetanus,  121 

tuberculosis,  119 
Bacteria,  111 

cultivation  of,  114 

elimination  of,  115 

infection  from,  115 

inoculation  of,  114 

intoxication  from,  115 

Koch's  law  in,  115 

pathogenic  action  of,  116 

resistance  to,  116 

staining  of,  114 

of  suppuration,  118 

varieties  of,  118 
Bandage    or   bandages,    aim    and 
chest,  67 

Barton's,  41 
modified,  42 

black,  90 

Borsch's,  87 


Bandage  or  bandages,  circular,  23 
compound,  27 
compressor,  of  breast,  71 
demi-gauntlet,  55 
Desault's,  64 
dimensions  <>t',  20 
elastic-webbing,  92 
Esmarch's,  296 
of  eye,  crossed,  50 
figure-of-eight,  26 

of  chest,  anterior,  69 
posterior,  70 

of  elbow,  58 

of  knee,  77 

of  knees,  79 

of  leg,  83 

of  neck  and  axilla,  62 
of  finger,  spiral,  54 
flannel,  90 
of  foot,  American,  81 

French,  82 
four-tailed,  30 

of  chin,  31 

of  head,  31 
gauze,  88 
gauntlet,  54 
Gibson's,  44 
handkerchief,  32 
hardening,  93 
of  the  head.  41 

and  neck,  49 

recurrent,  46 

transverse  recurrent,  48 
of  jaw,  oblique,  45 
Liebreich's,  86 
for  lithotomy,  86 
of  the  lower  extremity,  73 
many-tailed,  30 

of  abdomen,  31 
oblique,  23 
occipito-facial,  52 
occipito-frontal,  53 
paraffin,  157 
plaster-of-Paris,  application  of,  95 

preparation  of,  94 

removal  of,  103 

trapping  of,  102 
recurrent,  26 

of  stump,  84 
removal  of,  22 
roller,  18 


606 


INDEX. 


Bandage  or  bandages,  roller,  double, 
20 
single,  20 
rubber,  90 
scissors,  22 
of  Scultetus,  87 
silicate  of  potassium,  106 

of  sodium,  106 
special,  81 
spica-,  25 

of  buttock,  77 
of  foot,  80 

of  groins,  double,  76 
single,  ascending,  73 
descending,  75 
of  shoulder,  59,  61 
ascending,  59 
descending,  61 
of  thumb,  56 
spiral,  23 
of  chest,  69 
reversed,  24 

of  lower  extremity,  82 
of  penis,  84 

of  upper,  extremity,  57 
starched,  106 
sterilized,  146 
suspensory,  of  breast,  71 
T,  27 

of  chest,  27 

double,  29 
double,  29 
of  groin,  28 
of  nose,  double,  30 
single,  27 
of  the  trunk,  69 
of  upper  extremity,  54 
varieties  of,  23 
Velpeau's,  62 
Bandaging,  17 
rules  for,  21 
Barton's  bandage,  41 

modified,  42 
Bavarian  dressing,  100 
Bedsores,  329 
Beta-naphthol,  133 
Bichloride  cotton,  146 
gauze,  145 
of  mercury,  129 
of  palladium  catgut,  141 
Bier's  osteoplastic  amputation,  481 


Binders'  board  splints,  108,  342 
Bisaxillary  cravat,  36 
Black  bandages,  90 
Bladder,  hemorrhage  from,  310 

irrigation  of,  266 

sterilization  of,  152 
Blood,  transfusion  of,  198 
Bloodletting,  192 
Boiled  catgut,  140 
Bond's  splint,  379 
Bone  chips,  preparation  of,  220 
Bone-grafting,  219 
Bones  of  forearm,  fractures  of,  375 
incomplete  fracture  of,  377 

of  leg,  fractures  of,  395 

ambulatory  treatment  of,  400 
Boric  acid,  135 
Boro-salicylic  powder,  135 
Borsch's  eye  bandage,  87 
Bougies,  259,  261 

bulbous,  262 

filiform,  262 

oesophageal,  211 

rectal,  212 

sterilization  of,  155,  259 
Brachial  artery,  ligation  of,  459 

plexus,  nerves   of,  exposure  of, 
562 
Bran  bags,  343 
Breast,  excision  of,  570 

suspensory  cap  of,  38 

and    compressor    bandage    of, 
71,  72 

triangular  cap  of,  38 
Bromide  of  ethyl,  254 
Bruises,  323 
Brush-burn,  324 
Bulbous  bougies,  262 
Buried  sutures,  273 
Burns,  324 

white-lead  dressing  in,  325 
Buttock,  spica-bandage  of,  77 
Button  suture,  276 

CANTHAKIDAL  collodion,  187 
Capillary   hemorrhage,   treat- 
ment of,  306 
Capsicum,    counterirritation    from, 

186 
Carbolic  acid,  130 
Carbolized  gauze,  146 


/    DEX. 


607 


Carbuncle,  strapping  of,  177 
Garden's  amputation  at  knee,  523 
Carotid   artery,   common,    Ligation 
of,  451 
external,  ligation  of,  453 
internal,  ligation  of,  454 
Carpal  bones,  dislocation  of,  427 

fractures  of,  382 
Cartilages,  costal,  fractures  of,  354 

semilunar,  dislocation  of,  437 
Catgut,    bichloride    of    palladium, 
141 

boiled,  140 

cumol,  140 

chromic  acid,  141 

chromicized,  141 

drainage,  142 

Elsberg's,  141 

formalin,  140 

ligatures,  139 

sterilized,  dry,  139 

sutures,  139 

von  Bergmann's,  139 
Catheters,  259 

female,  introduction  of,  264 

flexible,  260 

introduction  of,  260 

metallic,  259 

securing,  in  bladder,  265 

soft-rubber,  261 

sterilization  of,  155,  259 
Catheterization  of  ureters,  264 
Cauterization  in  hemorrhage,  301 
Cautery,  actual,  189 

irons,  190 
Celluloid  thread,  142 
Chemical  sterilization,  method  of, 

149 
Chest,   figure-of-eight    bandage   of, 
anterior,    69 
posterior,  70 

spiral  bandage  of,  69 

strapping  of,  172 

T-bandage  of,  27 
double,  29 
Chin,  four-tailed  bandage  of,  31 
Cholecystotomy,  591 
Chopart's  amputation  of  foot,  513 
Chloride  of  ethyl,  233 

of  sodium,  136 

of  zinc,  134 


Chloroform,  2-49 

administration  of,  251 

anaesthesia,     accidents      during, 
252 

counter-irritation  from,  185 

and  ether,  253 

and  oxygen,  253 

preparation  of  patient  for,  250 
Chromic  acid  catgut,  141 
Chromicized  catgut,  141 
Chronic  abscess,  313 
Circular  amputation,  477 
of  leg,  519 

bandage,  23 

suture  of  intestine,  280 
Circumcision,  570 
Clavicle,  dislocations  of,  416 
of  acromial  end  of,  417 
of  sternal  end  of,  417 

excision  of,  542 

fractures  of,  358 
in  children,  363 

Sayre's  dressing  for,  360 
Clinical  thermometer,  227 
Closed  fracture,  335 
Coaptation  sutures,  268 
Cocaine,  234 
Coccyx,  dislocations  of,  414 

excision  of,  550 

fractures  of,  356 
Cold,  anaesthesia  from,  233 

in  hemorrhage,  299 

water  dressings,  182 
Colles's  fracture,  377 
Colostomy,  inguinal,  586 

lumbar,  585 

Maydl's,  586 
Comminuted  fracture,  335 
Complete  dislocations,  411 

fracture,  333 
Complicated  dislocation,  411,  442 

fracture,  335 
Compound  bandages,  27 

dislocation,  411,  442 

dorso-bis-axillary  cravat,  37 

fracture,  335 

treatment  of,  404 
Compresses,  168 

in  hemorrhage,  2'. '3 
Compression,  225 

digital,  in  hemorrhage,  292 


608 


INDEX. 


Compressor  bandage  of  breast,  71 

of  both  breasts,  72 
Congenital  dislocation,  443 
Constitutional  treatment  of  hemor- 
rhage, 291 
Continued  sutures,  274 
Contused  wounds,  320 
Contusions,  323 
Coronoid  process  of  ulna,  fractures 

of,  375 
Costal  cartilages,  dislocation  of,  415 

fractures  of,  354 
Cotton,  107 

absorbent,  167 

bichloride,  146 

gloves,  156 

sterilized,  147 
Counter-irritation,  184 

from  aqua  ammonia,  186 

from  chloroform,  185 

from  capsicum,  186 

from  hot  water,  184 

from  mustard,  185 

Seguin's  method,  188 

from  tincture  of  iodine,  185 

from  turpentine,  184 
Cravat,  bis-axillary,  36 

compound  dorso-bis-axillary,  37 

dorso-axillary,  37 

gluteo-inguinal,  39 

mento-vertico-occipital,  35 
Crossed  bandage  of  eye,  50 

of  eyes,  51 
Crural  nerve,  anterior,  exposure  of, 

564 
Cultivation  of  bacteria,  114 
Cumol  catgut,  140 
Cupping,  193 

dry,  193 

wet,  193 
Cystoscope,  222 
Czerny  suture,  280 

DEEP    sutures    in    hemorrhage, 
302 
Deformity  in  fracture,  337 

gunstock,  370 
Demi-gauntlet  bandage,  55 
Desault's  bandage,  64 
Descending  spica-bandage  of  groin, 
75 


Diffused  suppuration,  314 
Digital     compression     in      hemor- 
rhage, 292 
Dimensions  of  bandages,  20 
1  disinfection,  methods  of,  125 
Dislocation  or  dislocations,  411 
of  acromial  end  of  clavicle,  417 
of  the  ankle,  438 
of  astragalus,  439 
of  carpal  bones,  427 
of  the  clavicle,  416 
of  the  coccyx,  414 
complete,  411 
complicated,  411,  442 
compound,  411,  442 
congenital,  443 
of  the  costal  cartilages,  415 
of  the  elbow,  423 
of  the  fibula,  438 
of  the  fingers,  427 
habitual,  412,  443 
of  head  of  radius,  425 
of  the  hip,  430 

anomalous,  435 

downward,  432 

forward,  432 

iliac,  430 

ischiatic,  430 

posterior,  430 

pubic,  434 

thyroid,  432 

upward,  433 
of  humerus,  subcoracoid,  419 

subglenoid,  419 
of  the  hyoid  bone,  415 
of  the  knee,  436 
of  the  lower  jaw,  414 
of  the  metacarpal  bones,  427 
of  the  metatarsal  bones,  440 
old,  412,  440 
partial,  411 
of  the  patella,  435 
pathological,  443 
of  the  pelvis,  416 
of  phalanges  of  toes,  440 
recent,  412 
of  the  ribs,  415 
of  the  scapula,  41 8 
of  the  semilunar  cartilages,  437 
of  the  shoulder,  419 
simple,  411 


LXDh'X. 


609 


Dislocation  or  dislocations,  of  sterna] 
end  of  clavicle,  1 17 
of  the  sternum,  41(5 
subclavicular,  of  humerus,  419 
subspinous,  of  humerus,  420 
of  the  tarsal  bones,  439 
of  the  thumb,  428 
treatment  of,  412 
of  the  ulna,  426 
of  the  vertebrae,  413 
of  the  wrist,  426 
Dorsal  dislocation  of  the  hip,  430 
Dorsalis  pedis  artery,  ligation  of, 

473 
Dorso-axillary  cravat,  37 
Double  ligature,  287 
spiea-bandage  of  groins,  76 
T-bandage,  29 
of  nose,  30 
Downward  dislocation  of  the  hip, 

432 
Drainage,  catgut,  142 
horsehair,  142 
tubes,  142 
Dressing   or    dressings,    antiseptic, 
improvised,  146 
aseptic,  improvised,  146 

methods  of,  149 
Bavarian,  100 
cold  water,  182 
dry  sterilized  unitize,  147 
fixed,  93 
gauze,  145 

moist,  method  of,  161 
sterilized  ^auze,  147 
plaster-of-Paris,  93 
application  of,  93 
interrupted,  97 
of  wounds,  318 
Dry  cupping,  193 
dressing,  method  of,  149 
sterilized  gauze  dressing,  147 
Dupuytren's  amputation  at  shoul- 
der-joint, 504 

ELASTIC  constriction  in  hemor- 
rhage, 294 
ligature,  289 
Elastic-webbing  bandage,  92 
Elbow,  amputation  at,  497 
dislocations  of,  423 
39 


Elbow,  figure-of-eight   bandage  of, 

58 
Elbow-joint,  excision,  ~>:\7 
Electricity,  injuries  from,  326 
Electrolysis,  220 
Elimination  of  bacteria,  115 
Elliptical  amputation,  47*. > 

of  [eg,  5111 
End-to-end    intestinal    anastomosis, 

285 
Enema,  glycerin,  213 

nutritious,  213 
Enemata,  212 

Epiphyses,  separation  of,  345 
symptoms  of,  346 
treatment  of,  347 
Epistaxis,  307 
Erichsen's  ligature,  289 
Esmarch's  bandage,  296 

inhaler,  251 

tube,  296 
Estlander's  operation,  543 
Ether,  241 

administration  of,  244 

after-effects  of,  248 

and  chloroform,  253 

first  insensibility  from,  246 

and  nitrous  oxide  gas,  248 

and  oxygen,  249 

preparation  of  patient  for,  242 
Etherization,  accidents  during,  246 
Ethyl  bromide,  254 
Eucaine  hydrochlorate,  236 
Excision  or  excisions,  533 

of  ankle-joint,  548 

of  astragalus,  549 

of  breast,  570 

of  clavicle,  542 

of  coccyx,  550 

of  elbow-joint,  537 

of  hip-joint,  544 
anterior,  546 

of  joints,  533 

instruments  for,  534 

of  knee-joint,  546 

of  lower  jaw,  552 

of  metacarpophalangeal  joints, 
541 

of  os  calcis,  550 

of  patella,  547 

of  scapula,  543  ... 


610 


INDEX. 


Excision  or  excisions,  of  shoulder- 
joint,  536 

of  testicle,  591 

of  upper  jaw,  55] 

of  wrist,  539 
Exploring-needle,  21 7 
Exploring-trocar,  217 
Extremity,     upper,     bandages    of, 

54 
Eyes,  bandage  of,  crossed,  51 

FACIAL  artery,  ligation  of,  455 
nerve,  exposure  of,  562 
Faradization,  222 
Fascia,  strains  of,  331 
Feet,  sterilization  of,  151 
Felt  splints,  109,  342 
Female   catheter,   introduction  of, 

264 
Femoral  artery,  ligation  of,  468 
Femur,  dislocation  of,  see  Hip. 
fractures  of,  384 

ambulatory  treatment  of,  392 
in  children,  391 
of  lower  end  of.  390 
of  shaft  of,  388' 
of  upper  extremity  of,  384 
Fermenting  poultice,  179 
Fibula,  dislocation  of,  438 
fractures  of,  401 
resection  of,  548 
Figure-of-eight  bandage,  26 
of  elbow,  58 
of  knee,  77 
of  knees,  79 
'of  leg,  83 

of  neck  and  axilla,  62 
Filiform  bougies,  262 
Fingers,  amputation  of,  490 
dislocations  of,  427 
fractures  of,  382 
spiral  bandage  of,  54 
Fixed  dressings,  93 
Flannel  bandage,  90 
Flaxseed  poultice,  178 
Fly  blister,  187 
Fomentations,  hot,  179 
Foot,  amputations  of,  507 
bandage  of,  American,  81 

French,  82 
spica-bandage  of,  80 


Forced  respiration,  206 
Forceps,  anastomosis,  286 

artery,  301 

haemostatic,  296 
Forearm,  amputations  of,  496 
circular,  4i)6 
modified  circular,  497 

fractures  of  bones  of,  375 
Formaldehyde,  133 
Formalin,  133 

catgut,  140 

gelatin,  133 
Forward   dislocations   of   the  hip, 

432 
Four-tailed  bandage,  30 

of  chin,  31 
Fracture  or  fractures,  333 

anaesthetics  in,  338 

bed,  341 

of  bones  of  fingers,  382 
of  forearm,  375 
of  leg,  395 

-box,  343 

of  carpal  bones,  382 

of  clavicle,  358 
in  children,  363 

closed,  335 

of  coccyx,  356 

Colles's,  377 
reversed,  381 

comminuted,  335 

complete,  333 

complicated,  335 

compound,  335 
treatment  of,  404 

of  coronoid  process  of  ulna,  375 

of  costal  cartilages,  354 

deformity  in,  337 

evaporating  lotions  in,  344 

examination  of,  337 

of  femur,  384 

of  fibula,  401 

green-stick,  333 

gunshot,  334 

of  head  of  radius,  375 

of  humerus,  364 

of  hyoid  bone,  353 

incomplete,  333 

impacted,  335 

of  larynx,  353 

longitudinal,  336 


INDEX. 


611 


Fracture  or  fractures,  of  lower  end 
of  radius,  377 

extremity  of  humerus,  369 

jaw,  351 
of  malar  bone,  349 
massage  in,  245 
of  metacarpal  bones,  382 
of  metatarsal  bones,  403 
multiple,  335 
of  nasal  bones,  348 
of  neck  of  radius,  375 
oblique,  335 
of    olecranon    process   of    ulna, 

373 
open,  335 

treatment  of,  404 
of  the  patella,  393 

operative  treatment  of,  395 
of  pelvis,  355 
of  phalanges  of  finger,  382 

of  toes,  403 
Pott's,  401 

provisional  dressings  in,  339 
rack,  344 
of  radius,  375 
reduction  of,  340 
of  ribs,  353 
of  sacrum,  356 
of  scapula,  363 
setting  of,  340 
of  shaft  of  femur,  388 

of  humerus,  367 
simple,  335 
of  skull,  357 
of  sternum,  354 
subperiosteal,  334 
symptoms  of,  336 
of  tarsal  bones,  402 
of  tibia,  395 
of  trachea,  353 
transverse,  335 
of  ulna,  375 
ununited,  408 

of  upper  extremitv  of  humerus, 
364 

jaw,  350 

varieties  of,  333 

of  vertebrae,  356 

of  zygoma,  349 

Franklinization,  222 

Frontal  sinus,  trephining  of,  558 


GALVANO-CAUTERY,  221 
( rastro-duodenostomy,  597 
( rastro-enterostomy,  599 

Gastrostomy,  592 

Ssabanajew-Frank's,  593 

Witzel's,  595 
Gauntlet  bandage,  54 
Gauze  bandages,  88 

bichloride,  145 

carbolized,  146 

dressings,  145 

dry  sterilized,  147 
moist  sterilized,  147 

iodoform,  145 

pads,  158 

pledgets,  138 

sterilized,  147 
Gelatin  in  hemorrhage,  299 
General  anaesthesia,  233,  239 
Gibson's  bandage,  44 
Gloves,  cotton,  156 

rubber,  156 
Gluteal  artery,  ligation  of,  467 
Gluteo-femoral  triangle,  39 
Gluteo-inguinal  cravat,  39 
Glutol,  133 
Glycerin  enema,  213 

tampon,  168 
Gonococcus,  119 
Granny  knot,  272 
Green-stick  fracture,  333 
Gritti's  amputation    at   knee-joint, 

524 
Groin,  spica-bandage  of,  ascending, 
73 
double,  76 
single  descending,  75 

T-bandage  of,  28 
Guaiacol,  236 
Gunshot  fracture,  334 

wounds,  322 
Gunstock  deformity,  370 
Gutta-percha  splints,  342 
Gut  wool,  300 


HABITUAL  dislocation,  412, 443 
Haemostatic  forceps,  296 
Halsted's  mattress  suture,  279 
Hancock's  amputation  of  foot,  518 
Hand  or  hands,  amputations  of,  490 


612 


INDEX. 


Hand  or  hands,  removal  of  plaster- 
of-Paris  from,  103 

sterilization  of,  153 
Handkerchief  bandages,  32 
Hardening  bandages,  93 
Hare-lip  suture,  275 
Head,  bandages  of,  41 
oblique,  52 

four-tailed  bandage  of,  31 

and  neck  bandage,  49 

recurrent  bandage  of,  46 
transverse,  48 

V-bandage  of,  48 
Heat,  128 

Hemorrhage,  adrenalin  chloride  in, 
299 

antipyrin  in,  299 

arterial,   permanent    control    of, 
298 
temporary  control  of,  292 

from  bladder,  310 

capillary,  treatment  of,  306 

cauterization  in,  301 

cold  in,  299 

compresses  in,  293 

constitutional  treatment  of,  291 

deep  sutures  in,  302 

digital  compression  in,  292 

elastic  constriction  in,  294 

gelatin  in,  299 

hot  water  in,  299 

ligation  in,  302 

local  treatment  of,  291 

position  in,  298 

pressure  in,  300 

from  rectum,  311 

secondary,  treatment  of,  307 

styptics  in,  299 

torsion  in,  301 

tourniquets  in,  293 

treatment  of,  291 

from  urethra,  310 

venous,  treatment  of,  305 
Hernia,  trusses  for,  257  et  seq. 
Hey's  amputation  of  foot,  513 
Hilton's  method  in  abscess,  311 
Hip,  dislocation  of,  430 
anomalous,  435 
downward.  432 
forward.  432,  433 
iliac,  430 


Hip,  dislocation  of,  ischiatic,  430 
posterior,  430 
pubic,  434 
thyroid,  432 
dorsal  dislocation  of,  430 
Hip-joint,  amputations  at,  527 

excision  of,  544 
Holocaine  hydrochlorate,  236 
Horsehair  drainage,  142 
Horsley's  wax,  300 
Hot  air,  application  of,  226 
fomentations,  179 
water,  counter-irritation  from,  184 
in  hemorrhage,  299 
Howard's  method  of  artificial  res- 
piration, 202 
Humerus,  fractures  of,  364 
lower  extremity  of,  369 
shaft  of,  367 
upper  extremity  of,  364 
resection  of,  537 
separation  of  upper  epiphysis  of, 

366 
subclavicular  dislocation  of,  419 
subcoracoid  dislocation  of,  419 
subglenoid  dislocation  of,  419 
subspinous  dislocation  of,  420 
Hydrogen  peroxide,  134 
Hyoid  bone,  dislocation  of,  415 

fracture  of,  353 
Hypnotism,  anaesthesia  from,  255 
Hypodermic  injections,  214 
Hypodermoclysis,  200 

TCE-BAG,  183 

J_     Iliac  arterv,  common,  ligation 
of,  463  _ 
external,  ligation  of,  466 
internal,  ligation  of,  465 
dislocation  of  the  hip,  430 
Immediate  irrigation,  180 
Immunity,  117 
Impacted  fracture,  335 
Improvised  antiseptic  dressings,  146 
Incised  wounds,  318 
Incision  of  abscess,  314 
Incomplete  fracture,  333 

of  bones  of  forearm,  377 
Infected   wounds,  antiseptic   treat- 
ment of,  164 
aseptic  treatment  of,  164 


INDEX. 


613 


Infection  from  bacteria,  115 
Inferior  dental  nerve,  exposure  of, 

561 
Infiltration  anaesthesia,  236 
Infusion  of  saline  solution,  200 
Inguinal  colostomy,  586 
Injection  in  abscess,  313 

of  antitoxins,  215 

spinal  arachnoid,  238 
Injections,  hypodermic,  214 

of  mercury,  216 

urethral,  267 
Injuries  from  electricity,  326 
Innominate  artery,  ligation  of,  447 
Inoculation  of  bacteria,  114 
Instruments,  sterilization  of,  154 
Interosseous  artery,  ligation  of,  463 
Interrupted   plaster-of-Paris   dress- 
ing, 97 

suture,  273 
Intestinal  anastomosis,  280 
end-to-end,  285 
lateral,  283 
Semi's  method,  283 

sutures,  278 
Intestine,  circular  suture  of,  280 
Intoxication  from  bacteria,  115 
Intravenous     injection     of    saline 

solution,  199 
Introduction  of  catheter,  262 
Intubation  of  larynx,  578 
feeding  after,  583 
operation  of,  580 
Iodoform,  131 

collodion,  132 

emulsion,  132 

ethereal  solution  of,  132 

gauze,  145 
Irrigation,  180 

of  bladder,  266 

immediate,  180 

mediate,  182 
Ischiatic  dislocation  of  hip,  430 
Isinglass  plaster,  171 

JACKET,   plaster-of-Paris,  appli- 
cation of,  98 
Jaw,  dislocation  of,  414 
lower,  excision  of,  552 
oblique  bandage  of,  45 
upper,  excision  of,  551 


Joints,  excision  of,  533 

strapping  of,  176 
Junk  bags,  343 
Jury-mast,  application  of,  100 

KIDNEY,  operations  upon,  584 
Knee,  dislocations  of,  436 
figure-of-eight  bandage  of, 
77 
Knee-joint,  amputations  at,  522 
arthrectomy  of,  547 
excision  of,  546 
Knees,  figure-of-eight    bandage  of, 

79 
Koch's  law,  115 
Krause's  method  of  skin-grafting, 

219 
Kreolin,  135 

LABOKDE'S  method  of  artificial' 
respiration,  206 

Lacerated  wounds,  319 

Laminectomy,  558 

Larrey's  amputation   at    shoulder- 
joint,  503 

Laryngotomy,  577 

Laryngo-tracheotomy,  578 

Larynx,  fracture  of,  353 
intubation  of,  578 

Lateral  ligature  in  venous  hemor- 
rhage, 305 

Lavage,  210 

Leather  splints,  107,  342 

Leech,  mechanical,  196 

Leeching,  195 

Leg,  amputations  of,  519 
bones  of,  fracture  of,  395 
figure-of-eight  bandage  of,  83 

Lembert's  suture,  278 

Lengthening  of  tendons,  568 

Liebreich's  eye-bandage,  86 

Ligation  of  abdominal  aorta,  463 
of  anterior  tibial  artery,  471 
of  arteries,  445 
of  axillary  artery,  456 
of  brachial  artery,  459 
of  common  carotid  artery,  451 
of  common  iliac  artery,  463 
of  dorsalis  pedis  artery,  473 
of  external  carotid  artery,  453 


614 


INDEX. 


Ligation  of  external  iliac  artery,  4G6 

of  facial  artery,  455 

of  femoral  artery,  468 

of  gluteal  artery,  467 

in  hemorrhage,  302 

of  inferior  thyroid  artery,  451 

of  innominate  artery,  447 

of  internal  carotid  artery,  454 
iliac  artery,  465 
mammary  artery,  451 
pudic  artery,  467 

of  interosseous  artery,  463 

of  lingual  artery,  454 

of  occipital  artery,  455 

of  popliteal  artery,  470 

of  posterior  tibial  artery,  474 

of  radial  artery,  459 

of  sciatic  artery,  467 

of  subclavian  artery,  449 

of  superior  thyroid  artery,  454 

of  temporal  artery,  455 

transperitoneal,  of  iliac  arteries, 
465 

of  ulnar  artery,  461 

of  vertebral  artery,  450 

of  wounded  arteries,  304 
Ligature  or  ligatures,  catgut,  139 

double,  287 

elastic,  289 

Erichsen's,  289 

lateral    in   venous    hemorrhage, 
305 

method  of  securing,  271 

quadruple,  288 

silk,  138 

single,  286 

subcutaneous,  288 

in  vascular  growths,  286 
Lightning-stroke,  328 
Lingual  artery,  ligation  of,  454 

nerve,  exposure  of,  561 
Lint,  166 
Lisfranc's  amputation  of  foot,  512 

at  shoulder- joint,  505 
Lister's  aorta  compressor,  295 
Lithotomy,  588 

bandage  for,  86 

left  lateral,  588 

suprapubic,  589 
Local  anaesthesia,  232,  233 

treatment  of  hemorrhage,  291 


Longitudinal  fracture,  336 
Lower  extremity,  bandage  of,  73 
spiral  reversed  bandage  of,  82 

jaw,  fracture  of,  351 
Lumbar  colostomy,  585 

nephrectomy,  584 

MACKINTOSH,  144 
Malar  bone,  fracture  of,  349 
Malignant  oedema,  bacillus  of,  121 
Mammary    artery,    internal,    liga- 
tion'of,  451 
Many-tailed  bandage,  30 

of  abdomen,  31 
Massage,  224 

in  fractures,  345 
Mattress  suture,  275 
Maxilla,  excision  of,  551 
inferior,  fracture  of,  351 
superior,  fracture  of,  350 
Maydl's  colostomy,  586 
Mechanical  leech,  196 
Median  nerve,  exposure  of,  563 
Mediate  irrigation,  182 
Mento-vertico-occipital  cravat,  35 
Mercury,  bichloride  of,  129 

injections  of,  216 
Metacarpal  bones,  amputations  of, 
493 
dislocations  of,  427 
fractures  of,  382 
resection  of,  540 
Metacarpophalangeal  joints,  exci- 
sion of,  541 
Metatarsal   bones,   amputation   of, 
510 
dislocation  of,  440 
fractures  of,  403 
resection  of,  550 
Mikulicz   osteoplastic   amputation, 
518 
pack,  132 
Modified  circular  amputation,  479 
Moist  dressing,  method  of,  149 
modified  method  of,  149 
gauze  dressings,  147 
Moulded  plaster  splints,  102 

splints,  107 
Mouth-to-mouth  inflation,  202 
Mouth,  sterilization  of,  153 
Multiple  fracture,  335 


INDEX. 


615 


Murphy  button,  281 
Muscle-grafting,  220 
Muscles,  strains  of,  331 
Musculo-spiral  uerve,  exposure  of, 

563 
Mustard,    counter-irritation    from, 
185 

papers,  186 

plaster,  185 
Mycetoma,  123 

NASAL  bones,  fracture  of,  348 
cavities,  sterilization  of,  153 
Neck     and    axilla,    figure-of-eight 

bandage  of,  62 
Needle,  aneurism,  302,  447 

mounted,  270 

surgical,  269 
Needle-holder,  270 
Needles,  acupuncture,  189 
Nephrectomy,  abdominal,  584 

lumbar,  584 
Nephrorrhaphy,  584 
Nephrotomy,  584 

Nerve  or  nerves,   anterior    crural, 
exposure  of,  b6i 

of  brachial  plexus,  exposure  of, 
562 

external  popliteal,  exposure  of, 
564 

facial,  exposure  of,  562 

-grafting,  220,  559 

great  sciatic,  exposure  of,  563 

-implantation,  560 

inferior  dental,  exposure  of,  561 

internal  popliteal,   exposure    of, 
564 

lingual,  exposure  of,  561 

median,  exposure  of,  563 

musculo-spiral,  exposure  of,  563 

operations  upon,  559 

radial,  exposure  of,  563 

spinal  accessory,  exposure  of,  563 

-stretching,  559 

superior  maxillary,  exposure  of, 
560 

supra-orbital,  exposure  of,  560 

suture  of,  559 

ulnar,  exposure  of,  563 
Neural  anaesthesia,  237 
Neurectasy,  559 


Neurectomy,  559 
Neuroplasty,  560 
Neurorrhaphy,  559 
Neurotomy,  559 

Nitrous  oxide  gas,  240 

and  ether,  248 

and  oxygen,  241 
Nose,  double  T-bandage  of,  30 
Nutritous  enema,  213 

OAKUM,  166 
Oblique  bandage,  23 
of  head,  52 
of  jaw,  45 
fracture,  335 
Occipital  artery,  ligation  of,  455 
Occipito-facial  bandage,  52 
Occipitofrontal  bandage,  53 

triangle,  34 
(Esophageal  bougie,  211 
(Esophagotomy,  external,  592 
Oiled  muslin,  167 

silk,  167 
Old  dislocation,  412,  440 
Olecranon  process,  fractures  of,  373 
Open  fracture,  335 

treatment  of,  404 
Operating  bag,  148 
Operation,  or  operations,  antiseptic, 
details  of,  158 
aseptic,  details  of,  157 
preparation  for,  150 
upon  kidney,  584 
upon  nerves,  559 
upon  tendons,  564 
Orthoform,  136 
Os  calcis,  excision  of,  550 
Osteoplastic  resection  of  skull,  556 
Osteotomy,  599 
Oval  amputation,  479 
Oxygen  and  chloroform,  253 
and  ether,  249 
and  nitrous  oxide  gas,  241 

PADS,  gauze,  138 
Panelectroscope,  224 
Paper,  parchment,  168 
splints,  342 
waxed,  167 
Paquelin's  thermo-cautery,  190 
Paraffin-bandage,  107 


616 


INDEX. 


Paraffin-paper,  167 
Parchment  paper,  168 
Partial  dislocation,  411 
Passive  motion,  225 
Pasteboard  splints,  108 
Patella,  dislocations  of,  435 
excision  of,  547 
fractures  of,  393 

operative  treatment  of,  395 
Pathogenic  action  of  bacteria,  116 
Pathological  dislocations,  443 
Patient,  preparation  of,  for  aseptic 

operation,  150 
Pelvic  supporter  for  application  of 

plaster-of-Paris  bandage,  96 
Pelvis,  dislocations  of,  416 

fractures  of,  355 
Penis,  spiral  reversed  bandage  of, 

_84 
Periosteal    flaps,    in     amputation, 

482 
Permanganate  of  potassium,  136 
Peroxide  of  hydrogen,  134 
Petit's  tourniquet,  294 
Phalanges   of   fingers,    dislocations 
of,  427 
fractures  of,  382 
of  toes,  dislocation  of,  440 
fractures  of,  403 
Pirogoffs    amputation    at    ankle- 
joint,  515 
Plaster  or  plasters,  169 
adhesive,  169 
bandage  saw,  105 

shears,  105 
isinglass,  171 
resin,  170 

rubber  adhesive,  170 
soap,  171 
spice,  186 
swan's  down,  170 
zinc  oxide  adhesive,  170 
Plaster-of-Paris    bandage,    applica- 
tion of,  95 
preparation  of,  94 
removal  of,  103 
trapping  of,  102 
dressings,  93 

application  of,  93 
interrupted,  97 
uses  of,  106 


Plaster-of-Paris  jacket,  application 
of,  98 

removal  of,  from  hands,  103 

splints,  343 
moulded,  102 
Plate  suture,  276 
Pledgets,  gauze,  138 
Poisoned  wounds,  321 
Popliteal  artery,  ligation  of,  470 

nerve,  external,  exposure  of,  564 
internal,  exposure  of,  564 
Position  in  hemorrhage,  298 
Posterior   dislocation    of  the    hip, 
430 

figure-of-eight  bandage  of  chest, 
70 
Potain's  aspirator,  208 
Potassium  permanganate,  136 
Pott's  fracture,  401 
Poultices,  177 

antiseptic,  179 

fermenting,  179 

flaxseed,  178 

soap,  178     - 

starch,  178 
Powder,  boro-salicylic,  135 
Powder-burns,  323 
Pressure  in  hemorrhage,  300 
Protective,  143 

Pubic  dislocation  of  the  hip,  434 
Pudic  artery,  internal,  ligation  of, 

467 
Puncturation,  192 
Punctured  wounds,  321 
Pylorectomy,  597 
Pyloroplasty,  596 
Pyrozone,  135 

QUADRUPLE  ligature,  288 
Quilled  suture,  275 
Quilt  suture,  275 

RADIAL  artery,  ligation  of,  459 
nerve,  exposure  of,  563 
Radius,  dislocation  of  head  of,  425 
fractures  of,  375 
of  head  of,  375 
of  lower  end  of,  377 
of  neck  of,  375 
resection  of,  538 
Raw-hide  splints,  107 


INDEX. 


617 


Ray-fungus,  122 
lucent  dislocations,  412 
Rectal  bougie,  212 

tube,  211 
Rectum,  hemorrhage  from,  311 

sterilization  of,  153 
Recurrent  bandage,  26 
of  head,  46 

transverse,  48 
of  stump,  84 
Reef-knot,  271 

Regional  anaesthesia,  232,  237 
Relaxation  sutures,  268 
Removal  of  bandages,  22 

of  plaster-of-Paris   bandage,   103 

of  sutures,  278 
Resection  or  resections,  533 

of  fibula,  548 

of  humerus,  537 

of  metacaipal  bone,  540 

of  metatarsal  bones,  550 

of  radius,  538 

of  ribs,  543 

of  skull,  osteoplastic,  556 

of  sternum,  543 

of  tibia,  548 

of  ulna,  538 
Resin  plaster,  170 
Resistance  of  tissues  to  bacteria,  116 
Respiration,  artificial,  201 

forced,  206 

rapid,  ana?stbesia  from,  234 
Retractors,  169 

Reversed  Colles's  fracture,  381 
Ribs,  dislocation  of,  415 

fractures  of,  353 

resection  of,  543 
Roller  bandage,  18 
double,  20 
single,  20 
Rontgen  rays,  228 
Room,  preparation  of,   for  aseptic 

operation,  150 
Roux's  amputation  at  ankle-joint, 

517 
Rubber  adhesive  plaster,  170 

bandage,  90 

-dam,  144 

gloves,  156 

tissue,  144,  168 
Rubefacients,  184 


SACRUM,  fractures  of,  356 
Salicvlic  acid,  L35 
Saline  solution,  136 
infusion  of,  200 

intravenous  injection  of,  199 
Sand  bags,  343 
Saw,  plaster  bandage,  105 
Savre's   dressing    for    fracture   of 

clavicle,  360 
Scalds,  324 

Scalp,  sterilization  of,  153 
Scapula,  acromion  process  of,  fract- 
ure of,  364 
body  of,  fracture  of,  364 
coracoid  process  of,  fracture  of, 

364 
dislocations  of,  418 
excision  of,  543 
fractures  of,  363 
neck  of,  fractures  of,  364 
Scarification,  192 

Scbleich's  anaesthetic  mixture,  253 
Sciatic  artery,  ligation  of,  467 

nerve,  great,  exposure  of,  563 
Scissors,  bandage,  22 
Scultetus  bandage,  87 
Secondary  hemorrhage,   treatment 
of,  307 
sutures,  269 
Sedillot's  amputation  of  leg,  521 
Sequin's  method  of  counter-irrita- 

~  tion,  188 
Semilunar  cartilages,  dislocation  of, 

437 
Senn's  method  of  intestinal  anas- 
tomosis, 283 
Separation  of  epiphyses,  345 

of  upper  epiphvsis  of  humerus, 
366 
Sepsis,  125 

Setting  of  fracture,  340 
Shears,     plaster-of-Paris    bandage, 

105 
Shock,  315 

prophylaxis  of,  316 
treatment  of,  317 
Shotted  suture,  277 
Shoulder,  dislocations  of,  419 

spica-bandage     of,    ascending, 

59 
descending,  61 


618 


INDEX. 


Shoulder-joint,  amputations  above, 
506 
amputation  at,  501 
excision  of,  536 
Signorini's  tourniquet,  296 
Silicate  of  potassium  bandage,  106 
splints,  343 
of  sodium  bandage,  106 
Silk  ligatures,  138 

sutures,  138 
Silkworm-gut,  139 
Silver  foil,  144 

salts,  133 
Silvester's  method  of  artificial  res- 
piration, 202 
Simple  dislocation,  411 

fracture,  335 
Single  ligature,  286 

spica-bandage  of  groin,  ascend- 
ing, 73 
descending,  75 
T-banclage,  27 
Sinuses,  314 
Skiagraphy,  228 
Skin-grafting,  217 
Krause's,  219 
Thiersch's,  218 
Skull,  fracture  of,  357 

osteoplastic  resection  of,  556 
trephining  of,  553 
Slings,  30 
Soap  plaster,  171 

poultice,  178 
Sodium  chloride,  136 
Solution,  saline,  136 
infusion  of,  200 
intravenous  injection  of,  199 
Sounds,  261 
Spanish  windlass,  294 
Special  bandages,  84 
Spence's   amputation  at   shoulder- 
joint,  505 
Spica-bandage,  25 
of  buttock,  77 
of  foot,  80 
of  groin,  double,  76 
single  ascending,  73 
descending,  75 
of  shoulder,  ascending,  59 

descending,  61 
of  thumb,  56 


Spice  plaster,  186 
Spinal    accessory   nerve,    exposure 
of,  563 

arachnoid  injection,  238 
Spiral  bandage,  23 
of  chest,  69 
of  finger,  54 

reversed  bandage,  24 

of  lower  extremity,  82 
of  penis,  84 
of  upper  extremity,  57 
Splint  or  splints,  341 

binders'  board,  108,  342 

Bond's,  379 

felt,  109,  342 

gutta-percha,  342 

leather,  107,  342 

moulded,  107 
plaster,  102 

paper,  342 

pasteboard,  108 

plaster-of-Paris,  343 

raw-hide,  107 

silicate  of  potassium,  343 

Volkmann's,  399 

wooden,  341 
Sponges,  137 
Spores,  112 
Sprain-fracture,  331 
Sprains,  330 

strapping  in,  330 
Staffordshire  knot,  272 
Staining  of  bacteria,  114 
Staphylococcus    pyogenes    aureus, 

118 
Starched  bandage,  106 
Starch  poultice,  178 
Sterilization  of  bladder,  152 

of  bougies,  155,  259 

of  catheters,  155,  259 

of  feet,  151 

of  hands,  153 

of  instruments,  154 

methods  of,  125 

of  mouth,  153 

of  nasal  cavities,  153 

of  rectum,  153 

of  scalp,  153 

of  stomach,  152 

of  urethra,  152 

of  vagina,  152 


INDEX. 


619 


Sterilized  bandages,  146 
catgut,  139  ei  seq. 
cotton,  147 

dry  gauze  dressings,  147 
gauze,"  147 

moist  gauze  dressings,  147 
water,  137 

Sternal  end  of  clavicle,  dislocation 

of,  417 
Sternum,  dislocation  of,  416 

fractures  of,  354 

resection  of,  543 
Stomach,  sterilization  of,  152 
Stomach-pump,  210 

-tube,  209 
Strains  of  fascia,  331 

of  muscles,  331 
Strapping,  171 

ankle-joint,  176 

carbuncle,  177 

chest,  172 

joints,  176 

in  sprains,  330 

testicle,  171 

ulcers,  173 
Streptococcus  pyogenes,  119 
Streptothrix  Madura3,  123 
Stump,  recurrent  bandage  of,  84 
Styptics  in  hemorrhage,  299 
Subastragaloid  amputation,  514 
Subclavian  artery,  ligation  of,  449 
Subclavicular  dislocation  of  hume- 
rus, 419 
Subcoracoid  dislocation  of  humerus, 

419 
Subcutaneous  ligature,  288 
Subcuticular  suture,  274 
Subglenoid  dislocation  of  head  of 

humerus,  419 
Subperiosteal  fracture,  334 
Subspinous  dislocation  of  humerus, 

420 
Sulphocarbolate  of  zinc.  134 
Superior  maxillarv  nerve,  exposure 

of,  560 
Suppuration,  bacteria  of,  118 
^  diffused,  314 
Supraorbital    nerve,    exposure    of, 

560 
Suprapubic  lithotomy,  589 
Surface  thermometer,  227 


Surgeon's  clothing,  157 

knot,  271 
Surgical  needles,  269 

operating  bag,  148 
Suspensory  bandage  of  breast,  71 

of  breasts,  72 
Suspensory  cap  of  breast,  38 
Suture  or  sutures,  268 

of  approximation,  269 

of  arteries.  303 

buried,  273 

button,  276 

circular,  of  intestine,  280 

of  coaptation,  268 

continued,  274 

Czerny,  280 

deep,  in  hemorrhage,  302 

Halsted's  mattress,  279 

harelip,  275 

interrupted,  273 

intestinal,  278 

Lembert's,  278 

mattress,  275 

method  of  securing,  271 

of  nerves,  559 

plate,  276 

quilled,  275 

quilt,  275 

of  relaxation,  268 

removal  of,  278 

secondary,  269 

shotted,  277 

silk,  138 

subcuticular,  274 

of  tendons,  567 

twisted,  275 

varieties  of,  273 

of  veins,  306 
Swan's  down  plaster,  170 
Svme's  amputation  at  ankle-joint, 
514 

TAMPON,  168 
glycerin,  168 
Tarsal  bones,  dislocation  of,  439 

fracture  of,  402 
Tarsometatarsal  amputations,  510 
T-bandage.  27 
of  chest,  27 
double,  29 
of  groin,  28 


620 


INDEX. 


T-bandage  of  nose,  double,  30 

single,  27 
Teale's  amputation,  480 

of  leg,  520 
Temporal  artery,  ligation  of,  455 
Tenaculum,  302 

Tendo-Achillis,  tenotomy  of,  565 
Tendon      or      tendons,      adductor 
longus,  tenotomy  of,  566 
anterior  tibial,  tenotomy  of,  566 
extensor  longus  digitorum,  ten- 
otomy of,  566 
proprius  pollicis,  tenotomy  of, 
566 
flexor  longus  pollicis,  tenotomy 

of,  566 
hamstring,  tenotomy  of,  566 
lengthening  of,  568 
operations  upon,  564 
peroneal,  tenotomy  of,  566 
posterior  tibial,  tenotomy  of,  565 
stemo-cleido-mastoid,     tenotomy 

of,  566 
suture  of,  567 
primary,  567 
secondary,  568 
transplantation  of,  569 
Tenotomy,  564 
Tent,  168 
Testicle,  excision  of,  591 

strapping  of,  171 
Tetanus,  bacillus  of,  121 
Thermo-cautery,  Paquelin's,  190 
Thermometer,  clinical,  227 

surface,  227 
Thiersch's  method  of  skin-grafting, 

218 
Thread,  celluloid,  142 
Thumb,  dislocation  of,  428 

spica-bandage  of,  56 
Thyroid    artery,    inferior,    ligation 
of,  451 
superior,  ligation  of,  454 
dislocation  of  hip,  432 
Tibia,  fracture  of,  395 

resection  of,  518 
Tibial  artery,  anterior,  ligation  of, 
471/ 
posterior,  ligation  of,  474 
Tincture  of  iodine,   counter-irrita- 
tion from,  185 


Toes,  amputations  of,  507 

dislocation  of,  440 
Torsion  in  hemorrhage,  301 
Tourniquets,  293 

in  amputations,  486 

Petit's,  294 

Signorini's,  296 
Toxins,  116 

Trachea,  fracture  of,  353 
Tracheal  dilators,  572 
Tracheotomy,  570 

director,  574 

operation  of,  574 
Tracheotomy-tubes,  572 
Transfixion,  amputation  by,  478 
Transfusion,  arterial,  199 

of  blood,  198 
Transperitoneal    ligation    of    iliac 

arteries,  465 
Transplantation  of  tendons,  569 
Transverse  fracture,  335 
Trapping  plaster-of-Paris  bandage, 

102 
Trephining  antrum  of  Highmore, 
556 

frontal  sinus,  558 

skull,  553 
Triangular  cap  of  breast,  38 
Tripier's  amputation  of  foot,  518 
Trunk,  bandage  of,  69 
Truss  or  trusses,  255 

for  femoral  hernia,  257 

for  inguinal  hernia,  257 

for  irreducible  hernia,  258 

for  umbilical  hernia,  258 
Tubercle  bacillus,  119 
Tuberculous  abscess,  313 
Turpentine,  counter-irritation  from, 
184 

stupe,  185 
Twisted  suture,  275 


ULCEES,  strapping  of,  173 
Ulna,  dislocations  of,  426 
fractures  of,  375 
resection  of,  538 
Ulnar  artery,  ligation  of,  461 

nerve,  exposure  of,  563 
Ununited  fractures,  408 
Upper  extremity,  bandages  of,  54 


INDEX. 


621 


Upper   extremity,    spiral    reversed 
bandage  of,  57 

jaw,  fracture  of,  300 
Upward   dislocations    of   the    hip, 

433 
Ureters,  catheterization  of,  264 
Urethra,  hemorrhage  from,  310 

sterilization  of,  152 
Urethral  injections,  267 
Urethroscope,  223 


T7ACCINATION,  213 

V    _  Vagina,  sterilization  of,  152 
Varicocele,  operations  for,  591 
Vascular     growths,     ligatures    in, 

286 
V-bandage  of  head,  48 
Veins,  suture  of,  306 
Velpeau's  bandage,  62 
Venesection,  196 
Venous  hemorrhage,  treatment  of, 

305 
Vertebrae,  dislocations  of,  413 

fractures  of,  356 
Vertebral  artery,  ligation  of,  450 
Vesicants,  187 

Vesication    from    aqua    ammonia, 
188 
from  chloroform,  188 
Volkmann's  sliding  foot-piece,  385 
splint,  399 


WAXED  paper,  167 
Wet  cupping,  194 
White-lead  dressing  in   burns,  325 
Wooden  splints,  341 
AY<  x)d-\vool,  167 
Wounds,  contused,  320 
dressing  of,  318 
gunshot,  322 
incised,  318 

infected,  antiseptic  treatment  of, 
164 
aseptic  treatment  of,  164 
lacerated,  319 
poisoned,  321 
punctured,  321 
redressing  of,  162 
Wrist,  amputations  at,  495 
circular,  495 
dislocations  of,  426 
excision  of,  539 
Wyeth's  _     bloodless       amputation 
at  hip-joint,  529 
pins  in  amputation  at  shoulder- 
joint,  502 

X-EAY  burns,  328 
X-rays,  use  of,  228 

ZINC  chloride,  134 
oxide,  adhesive  plaster,  170 
sulpho-carbolate,  134 
Zygoma,  fracture  of,  349 


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INDEX.- 

ANATOMY^   Gray,  p.  11  ;  Treves,  30  ;  Gerrish  11;  Collins,  4. 

DICTIONARIES.     Dunglison   p.  9  ;  Duane,  8  ;  National,  4. 

PHYSICS.     Draper,  p.  8  ;  Martin  &  Rockwell,  19. 

PHYSIOLOGY".     Foster,   p.  lu  ;   Chapman,  5;   Schofield,  25;   Collins 
&  Rockwell,  6  ;  Hall,  12.  [Remsen,  24. 

CHEMISTRY.      Simon,  p   25  ;  Attfield.  3  ;  Martin  &  Rockwell,  19; 

PHARMACOLOGY.  Cushny,  p.  6;  Culbreih,  7. 

PHARMACY.     Caspari,  p.  5. 

MATERIA   MEDICA.     Calbreth,  p.  7  ;   Maisch,  19  ;   Farqnharson,  9  ; 

DISPENSATORY.     National,  p.  20.  [Bruce,  4  :  Scbleif,  24. 

THERAPEUTICS.      Hare,  p    13;  Fothergill.  in ;  Whitla,  31  ;  Hayein 
&  Hare,  14  ;  Bruce,  4  ;  Schleif,  24  ;  Cushny,  7  ;  Tirard,  29. 

PRACTICE.      Flint,  p.  10  ;     Loomis  &  Thompson,  18  ;     Malsbary,  19  ; 
Thompson,  29. 

DIAGNOSIS.     Musser,  p. 20;  Hare,  13;  Simon,  25;  Herrick,  14;  Hutchi- 
son &  Rainey,  15  ;  Collins,  6. 

CLIMATOLOGY.     Soil 7,  p.  26  ;  Hayem  &  Hare,  14. 

NERVOUS  DISEASES.     Dercum,  p   8  ;    Potts,  23. 

MENTAL  DISEASES.     Clouston,  p.  6  ;  Folsom,  10  ;  Potts,  23. 

BACTERIOLOGY.       Abbott,  p.  2 ;    Vaughan  &  Novy,  30  ;     Senn's 
(Surgical),  25.      Park,  22  ;  Coates,  6.  [Vale,  21. 

HISTOLOGY.     Klein,  p.  17  ;     Schafer.  24  ;    Dunham,  8  ;    Nichols  & 

PATHOLOGY.    Green,  p.  12;  Ewing,  9;  Coats.  6;  Nichols  &  Vale,  21. 

SURGERY.     Park,  p.  22 ;  Dennis,  8 ;  Roberts,  24 ;  Ashhurst,  3 ;  Treves,  29 ; 
Cheyne  &  Burgharrl,  B  ;  Gallaudet,  11. 

SURGERY— OPERATIVE.     Stimson,  p.  27  ;  Smith,  26  ;  Treves,  29. 

SURGERY— ORTHOPEDIC.     Young,  p.  31;  Whitman,  31. 

SURGERY— MINOR.     Wharton,  p.  30.  [Wippern  4. 

FRACTURES  and  DISLOCATIONS.    Samson,  p.  27.  [Ballerger,  & 

OPHTHALMOLOGY.    Norris  &  Oliver,  p.  21;  Nettleship,  21. 

OTOLOGY.  Politzer,  p.  23;  Burnett,  5;  Field.  10;  Bacon,  3. 

LARYNGOLOGY  and  RHINOLOGY.  Coakley,  p.  6  ; 

DENTISTRY.     Essig  (Prosthetic),  p.  9  ;  Kirk  (Operative),  17  ;   Ameri- 
can System   2;  Coleman,  6;  Burcba'd  4. 

URINARY  DISEASES.     Roberts,  p.  24  ;  Black.  4. 

VENEREAL    DISEASES.      Taylor,  p.  28  ;    Havden,  14  ;    Cornil,  6  ; 

SEXUAL  DISORDERS.     Fuller,  p   11  ;  Taylor,  28. 

DERMATOLOGY-      Hyde,  p.  1«  ;  Jackson,  16;   Pye-Smith,  23  ;  Mor- 
ris, 20  ;  Jamieson,  16  ;  Hardaway,  12  ;  Grindon,  12. 
GYNECOLOGY.      American   System,  p.  3  ;    Thomas    &   Mnnde,  29 

Emmet,  9  ;  Davenport,  7  ;  May,  19  ;  Dudlev.  8  ;  Crockett,  7. 
OBSTETRICS.     American  System,'  p.  3  ;    Davis,"  7  ;   Parvin,  22  ;   Play- 
fair.  22  ;  King,  17  ;  Jewett,  16  ;  Evans,  9. 
PEDIATRICS.    Smith,  p  26  ;  Thomson,  29  :  Williams,  31  ;  Tuttle,  30. 
HYGIENE.     Egbert,  p.  9  ;  Richardson,  24  ;  Harrington,  14. 
MEDICAL  JURISPRUDENCE.     Tavlor,  p.  28. 
QUIZ   SERIES,  POCKET  TEXT-BOOKS  and  MANUALS. 
Pp.  17,  25  and  27. 
8.1.01. 


2       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


ABBOTT  (A.  O.).  PRINCIPLES  OF  BACTERIOLOGY:  a  Practical 
Manual  for  Students  and  Physicians.  Fifth  edition  thoroughly 
revised  and  greatly  enlarged.  In  one  handsome  12mo.  vol.  of  585  pages, 
with  109  engrav.,  of  which  26  are  colored.    Cloth,  $2.75,  net. 


cessfully.  To  those  who  require  a 
condensed  yet  nevertheless  complete 
work  upon  Bacteriology  we  most 
cordially  recommend  it. — The  Thera- 
peutic Gazette. 


One  of  its  most  attractive  charac- 
teristics is  that  the  directions  are  so 
clearly  given   that  anyone  with  a 
moderate  amount  of  laboratory  train- 
ing can,   with   a  little  care    as  to 
detail,  make   his   experiments    suc- 
AMERICAN  SYSTEM  OF  PRACTICAL  MEDICINE.    A  SYS- 
TEM OF  PRACTICAL  MEDICINE.     In  contributions  by  Various 
American   Authors.    Edited  by  Alfred  L.  Loomis,  M.D.,  LL.D., 
and  W.  Gilman  Thompson,  M.  D.      In  four  very  handsome  octavo 
volumes  of  about  900  pages  each,  fully  illustrated.     Complete  work 
noxo  ready.    Per  volume,  cloth,  $5;  leather,  $6;   half  Morocco,  $7. 
For  sale  by  subscription  only.    Prospectus  free  on  application. 


Every  chapter  is  a  masterpiece  of 
completeness,  and  is  particularly  ex- 
cellent in  regard  to  treatment,  many 
original  prescriptions,  formulas, 
charts  and  tables  being  given  for  the 
guidance  of  the  practitioner. 

"The  American  Svstem  of  Medi- 


cine" is  a  work  of  which  every 
American  physician  may  reasonably 
feel  proud,  and  in  which  eveiy  prac- 
titioner will  find  a  safe  and  trust- 
worthy counsellor  in  the  daily  re- 
sponsibilities of  practice. — The  Ohio 
Medical  Journal. 


AMERICAN  SYSTEM  OP  DENTISTRY.  In  treatises  by  various 
authors.  Edited  by  AVilbur  F.  Litch,  M.D.,  D.D.S.  In  three  very 
handsome  super-royal  octavo  volumes,  containing  about  3200  pages, 
with  1873  illustrations  and  many  full-page  plates.  Per  vol.,  cloth, 
$6;  leather,  $7  ;  half  Morocco,  $8.  For  sale  by  subscripti&n  only.  Pros- 
pectus free  on  application  to  the  Publishers. 

AMERICAN  TEXT-BOOKS  OF  DENTISTRY.  In  Contribu- 
tions by  Eminent  American  Authorities.  In  two  very  handsome 
octavo  volumes,  richly  illustrated  : 

PROSTHETIC  DENTISTRY.  Edited  by  Charles  J.  Essig,  M.D., 

D.D.S.,  Professor  of  Mechanical  Dentistry  and  Metallurgy,  Department 

of  Dentistry,  University  of  Pennsylvania,  Philadelphia.     New  (2d) 

edition.     807  pages,  1089  engravings.    Cloth,  $6 ;  leather,  $7.    Net. 

No  more  thorough  production  will  I      It  is  up  to  date  in  every  particular. 

be  found  either  in  this  country  or  in    It  is  a  practical  course  on  prosthetics 

any  country  where  dentistry  is  un-    which  any  student  can  take  up  dur- 

derstood  as  a  part  of  civilization. —  >  ing  or  after  college. — Dominion  Den- 

TJie  International  Dental  Journal,      tal  Journal. 

OPERATIVE  DENTISTRY.  Edited  by  Edward  C.  Kirk,  D.D.S., 

Professor  of  Clinical  Dentistry,  Department  of  Dentistry,  University 
of  Pennsylvania.  New  (2d)  edition.  857  pages,  897  engravings. 
Cloth,  $6.00;  leather,  $7/0.    Net. 


Written  by  a  number  of  practi- 
tioners as  well  known  at  the  chair 
as  in  journalistic  literature,  many  of 
them  teachers  of  eminence  in  our 
colleges.  It  should  be  included  in 
the  list  of  text- books  set  down  as 
most  useful  to  the  college  student.— 
The  Dental  News, 


It  is  replete  in  every  particular 
and  treats  the  subject  in  a  progressive 
manner.  It  is  a  book  that  every 
progressive  dentist  should  possess, 
and  Ave  can  heartily  recommend  it 
to  the  profession. — The  Ohio  Dental 
Journal. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.       3 

AMERICAN  SYSTEMS  OF  GYNECOLOGY  AND  OBSTET- 
RICS. In  treatises  by  the  most  eminent  American  specialists.  Gyne- 
cology edited  by  Matthew  D.  Mann,  A.M.,  M.D.,  and  Obstetrics 
edited  by  Barton  C.  Hirst,  M.  D.  In  four  large  octavo  volumes 
comprising  3(312  pages,  with  1092  engravings,  and  8  colored  plates.  Per 
volume,  cloth,  $5  ;  leather,  $6 ;  half  Bussia,  $7.  For  sale  by  subscrip- 
tion only.     Prospectus  free  on  application  to  the  Publishers. 

AMERICAN  TEXT-BOOK  OF  ANATOMY.     See  Gerrish,  page  1 1 . 

ALLEN  (HARRISON).  A  SYSTEM  OF  HUMAN  ANATOMY; 
WITH  AN  INTRODUCTORY  SECTION  ON  HISTOLOGY,  by 
E.  O.  Shakespeare,  M.D.  Comprising  813  double-columned  quarto 
pages,  with  380  engravings  on  stone,  109  plates,  and  241  wood  cuts 
in  the  text.  In  six  sections,  each  in  a  portfolio.  Price  per  section,  $3.50. 
Also,  bound  in  one  volume,  cloth,  $23.     Sold  by  subscription  only. 

A  PRACTICE  OF  OBSTETRICS  BY  AMERICAN  AU- 
THORS.    See  Jewett,  page  17. 

A   TREATISE   ON   SURGERY  BY  AMERICAN  AUTHORS. 

FOR  STUDENTS  AND  PRACTITIONERS  OF  SURGERY  AND 
MEDICINE.    Edited  by  Roswell  Park,  M.D.     See  page  22. 

ASHHURST   (JOHN,  JR.).   THE  PRINCIPLES  AND  PRACTICE 

OF  SURGERY.     For  the  use  of  Students  and  Practitioners.     Sixth 

and  revised  edition.     In  one  large  and  handsome  octavo  volume  of 

1161  pages,  with  656  engravings.   Cloth,  $6 ;  leather,  $7. 

As  a  masterly  epitome  of  what  has    text-book,  we  do  not  know  its  equal. 

been  said  and  done  in  surgery,  as  a    It  is  the  best  single  text-book  of 

succinct  and  logical  statement  of  the    surgery  that  Ave  have  yet  seen  in  this 

principles  of  the  subject,  as  a  model    country. — New  York  Post-Graduate. 

A  SYSTEM  OF  PRACTICAL  MEDICINE  BY  AMERICAN 
AUTHORS.  Edited  by  William  Pepper,  M.  D.,  LL.  D.  In  five 
large  octavo  volumes,  containing  5573  pages  and  198  illustrations.  Price 
per  volume,  cloth,  $5  ;  leather  $6  ;  half  Russia,  $7.  Sold  by  subscrip- 
tion only.    Prospectus  free  on  application  to  the  Publishers. 

ATTFEELD  (JOHN).     CHEMISTRY  :  GENERAL,  MEDICAL  AND 

PHARMACEUTICAL.     Sixteenth  edition,  specially  revised  by  the 

Author  for  America.    In  one  handsome  12mo.  volume  of  784  pages, 

with  88  illustrations.    Cloth,  $2.50,  net. 

It  is  replete  with  the  latest  inform-    been  adopted,  bringing  the  work  into 

ation,  and  considers  the  chemistry  of   close  touch  with  the  latest    United 

every  substance  recognized  officially    States  Pharmacojjoeia,  of  which  it  is 

or  in  general  practice.     The  modern    a  worthy  companion. — The  Pittsburg 

scientific  chemical  nomenclature  has    Medical  Review. 

BARNES  (ROBERT  AND  FANCOURT).  A  SYSTEM  OF  OB- 
STETRIC MEDICINE  AND  SURGERY.  Octavo,  872  pages,  with 
231  illus.     Cloth,  $5  :  leather,  $6. 

BACON  (GORHAM).     ON  THE  EAR.    New  (2d)  edition.    One  12mo. 
volume,   422  pages,    114   engravings   and   3   colored   plates.     Cloth, 
net,  $2.25. 
It  is  thebest  manual  upon  otology,    dents  of  medicine — Cleveland  J   \r- 
An  intensely  practical  book  for  stu-    nal  of  Medicine. 


4       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

BALLENGER  (W.  L.)  AND  WIPPERN  (A.  G.).  A  POCKET 
TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAB,  NOSE  AND 
THROAT.  In  one  handsome  12mo.  volume  of  525  pages,  with  148 
illustrations,  and  6  colored  plates.    Just  read'/.     Cloth,  $2.00,  net ; 

limp  leather,  $2.50,  net.  Lea's  Series  of  Pocket  Text-books,  edited  by 
Bern  B.  Gallattdet,  M.  D.    See  p.  17. 

BxlRTHOLOW  (ROBERTS).  CHOLERA;  ITS  CAUSATION,  PRE- 
VENTION AND  TREATMENT.  In  one  12mo.  volume  of  127  pages, 
with  9  illustrations.     Cloth,  $1.25. 

BILLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY. 

Including  in  one  alphabet  English,  French,  German,  Italian  and 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
In  two  very  handsome  imperial  octavo  volumes  containing  1574 
pages  and  two  colored  plates.  Per  volume,  cloth,  $6 ;  leather,  $7 ; 
half  Morocco,  $8.50.  For  sale  by  subscription  only.  Specimen  pages 
on  application  to  the  publishers. 

BLACK  (D.  CAMPBELL).  THE  URINE  IN  HEALTH  AND 
DISEASE,  AND  URINARY  ANALYSIS,  PHYSIOLOGICALLY 
AND  PATHOLOGICALLY  CONSIDERED.  In  one  12mo.  volume 
of  256  pages,  with  73  engravings.     Cloth,  $2.75. 


Concise,  practical,  clinical,  well 
illustrated  and  well  printed. — Mary- 
land Medical  Journal. 


A  concise,  yet  complete  manual, 
treating  of  the  subject  from  a  prac- 
tical and  clinical  standpoint. — The 
Ohio  Medical  Join  no  J. 

BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
Cloth,  $2  ;  leather,  $3. 

BRUCE  (J.  MITCHELL).  MATERIA  MEDIC  A  AND  THERA 
PEUTICS.  New  (6th)  edition.  In  one  12mo.  volume  of  600  pages 
Cloth,  $1.50,  net.    See  Student's  Series  of  Manuals,  page,  27. 


is  a  good  one  for  the  student  and  as 
a  busy  man's  reference. — Medical 
Review  of  Be  views. 


This  new  edition  increases  the 
value  and  more  firmly  establishes 
the  reputation  of  a  work  already 
known  and  appreciated.     The  book 

PRINCIPLES  OF  TREATMENT.     In  one  octavo  volume  of  625 

pages.     Cloth,  $3.75,  net. 

One  of  the  most  useful  books  in  .  facts,  and  receive  numerous  valuable 
which  the  practitioner  can  invest,  suggestions  that  he  can  carry  with 
It  is  a  book  worthy  of  reading  from  him  to  the  bedside  for  the  good  of 
cover  to  cover  ;  for  if  he  does  so  with  his  patient. —  Virginia  Medical  Semi- 
studious  intent,  he  will  learn  many    Monthly. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo  vol. 
of  1040  pages,  with  727  illustrations.     Cloth,  $6.50;  leather,  $7.50. 

BURCHARD  (HENRY  IL).  DENTAL  PATHOLOGY  AND  THER- 
APEUTICS.   Handsome  octavo,   575   pages,  with   400   illustrations. 
Cloth,  net,  $5.C0;  leather,  net,  $6.00. 
In  the  treatment  of  the  subject  the    a   valuable   text-honk   on  a  subject 
method   pursued   by   the   author   is    which  has  heretofore  not  been  side- 
logical  and  sequential.    The  work  is    quately  represented. — Dental  Cosmcs 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.       5 


BURNETT  GHARLESH.).  THE  EAR:  fTS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Ti  th  Use  of 
Students  ;ui<l  Practitionei  rid  edition.  In  one  8vo.  volume  of 
580  pages,  with  107  illustrations,     cloth,  $4;  leather, 

CARTER   11.  BRU  DEXELL)  AND  FROST  (.W.  ADAMS).   Oil  I 
THALMIC  SURGERY.      In  one  pocket-size  12mo.  volume  of  559 
pages,  with  91  engravings  and  one  plate.     Cloth,  $2.25.     See  Series  of 
Clinical  Manuals,  page  25. 

CAS  PARI  (CHARLES  JR.).  A  TREATISE  ON  PHARMACY. 
For  Students  and  Pharmacists.  In  one  handsome  octavo  volume  of 
680  pages,  with  2SS  illustrations.     Cloth,  $4.50. 

The  author's  duties  as  Professor  student  who  cannot  understand  must 
of  Theory  and  Practice  of  Pharmacy  be  dull  indeed.  The  book  is  full  of 
in  the  Maryland  College  of  Phar-  new,  clean,  sharp  illustrations, which 
macy,  and  his  contact  with  students  tell  the  story  frequently  at  a  glance, 
made  him  aware  of  their  exact  The  index  is  full  and  accurate. — 
wants  in  the  matter  of  a  manual.  National  Druggist. 
His    work    is   admirable,   and  the 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSI- 
OLOGY. New  (2d)  edition.  In  one  octavo  volume  of  921  pages, 
with  595  illustrations.     Cloth,  $4.25  ;  leather,  $5.25,  net. 

In  every  respect  the  work  fulfils  !  mirable  work   of  reference  for  the 


its  promise,  whether  as  a  complete 
treatise  for  the  student  or  as  an  ad- 


physician. — North  Carolina  Medical 
Journal. 


CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE   (W.  WATSON).     THE    TREATMENT    OF    WOUNDS, 

ULCERS  AND  ABSCESSES.    In  one  12mo.  volume  of  207  pages. 

Cloth,  $1.25. 

One    will    be    surprised     at    the  j  need  at  any  moment.     The  sections 

amount  of  practical  and  useful  in-  j  devoted  to  ulcers  and  abscesses  are 

formation  it  contains;  information  j  indispensable    to   any   physician. — 

that   the    practitioner  is    likely  to  |  The  Charlotte  Medical  Journal. 

CHEYNE  (W.  W.)  AND  BURGHARD  (F.  F.).  SURGICAL 
TREATMENT.  In  seven  octavo  volumes,  illustrated.  Now  read//. 
Volume  1,  299  pages  and  66  engravings.  Cloth,  $3.00  net.  Volume  2, 
382  pages,  141   engravings.     Cloth,  $4.00  net.     Vol.  3,  305  pages,  100 

engravings.     Cloth,  $3.50,  net.     Vol.  IV.,  383  pages,  138  engravings. 

Cloth,  $3.75,  net.  Vol.  V.,  in  press. 
The  book  is  especially  strong  from  ,  ment  receives  a  very  large  share  or 
the  practical  point  of  view,  and  con-  attention.  The  illustrations  are  clear 
tains  many  useful  hints,  often  upon  and  useful,  and  the  index  has  evi- 
minor  details  which  contribute  so  dently  been  very  carefully  made. — 
much  to   surgical   success.      Treat-    Medtcal  Record. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).  THE  DISSECTOR'S 
MAN  UAL.  In  one  12mo.  volume  of  396  pages,  with  49  engravings. 
Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  27. 

CLELAND  (JOHN).     A  DIRECTORY  FOR  THE  DISSECTION  OF 
THE  HUMAN  BODY.     In  one  12mo.  vol.  of  178  pages.    Cloth,  $1.25. 
CLEN1CAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  25. 


6       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL 
DISEASES.  New  (5th)  edition.  In  one  octavo  volume  of  750  pages, 
with  19  colored  plates.     Cloth,  $4.25,  net. 

ft-FoLSOM's  Abstract  of  Laws  of  U.  S.  on  Custody  of  Insane,  octavo, 
$1.50,  is  sold  in  conjunction  with  Clouston  on  Mental  Diseases  for 
$5.00,  net,  for  the  two  works. 

CLOWES  (FRANK).  AN  ELEMENTARY  TREATISE  ON  PRACTI- 
CAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS. From  the  fourth  English  edition.  In  one  handsome  12mo. 
volume  of  387  pages,  with  55  engravings.     Cloth,  $2.50. 

COAKLEY  (CORNELIUS  G.).    THE  DIAGNOSIS  AND  TREAT- 
MENT   OF    DISEASES    OF    THE    NOSE,    THROAT,    NASO- 
PHARYNX AND  TRACHEA.     New  (2d)  edition.     In   one   12mo. 
volume  of  556  pages,  with  103  engravings  and  4  colored  plates.  Cloth, 
$2.75.  net, 
The  work  is  a  convenient  and  in-  f  may  be  recommended  as  a  complete 
expensive  guide  to  the  entire  field  of   and  trustworthy  summary    of   the 
diseases  of  the  nose  and  throat,  which  I  subject. — Medical  News. 

COATES  (W.  E.,  JR.).  A  POCKET  TEXT-BOOK  OF  BACTE- 
RIOLOGY. In  one  handsome  12mo.  volume  of  about  350  pages,  with 
many  illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books,  edited 
by  Bern  B.  Gallaudet,  M.  D.     See  page  17. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol. 
of  829  pages,  with  339  engravings.     Cloth,  $5.50  y  leather,  $6.50. 

COLEMAN  (ALFRED).     A  MANUAL  OF  DENTAL  SURGERY 

AND  PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
handsome  octavo  vol.  of  412  pages,  with  331  engravings.    Cloth,  $3.25. 

COLLINS  (C.  P.).  A  POCKET  TEXT-BOOK  OF  MEDICAL 
DIAGNOSIS.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books, 
edited  by  Bern  B.  Gallaudet,  M.  D.     See  page  17. 

COLLINS  (H.   D.).      A  POCKET    TEXT-BOOK    OF    ANATOMY. 

In  one  handsome  12mo.  volume  of  about  400  pages,  with  many  illus- 
trations. Shortly.  Lea's  Series  of  Pocket  Text-books,  edited  by  Bern 
B.  Gallaudet,  M.  D.    See  page  17. 

COLLINS  (H.  D.)  AND  ROCKWELL  (TV.  H.).  A  POCKET 
TEXT-BOOK  OF  PHYSIOLOGY.  12mo.  of  316  pages,  with  153 
illustrations.  Just  ready.  Cloth,  $1.50;  flexible  red  leather,  $2.00, 
net.  Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallau- 
det, M.  D.    See  page  17. 


practitioner  with  the  advances  in 
this  subject. — The  Physician  and 
Surgeon. 


Well  written  and  up  to  date.  It 
is  a  manual  admirably  adapted  to 
teach  the  beginner  the  essentials  of 
physiology,    and    to    acquaint    the 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25 ;  leather,  $6.25. 

CORNEL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.  Translated,  with  Notes  and  Additions,  by 
J.  Henry  C.  Simes,  M.D.  and  J.  William  White,  M.  D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.    Cloth,  $3.75. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.       7 


CROCKETT  (M.   A..).      A  POCKET  TEXT-BOOK   OF  DISEASES 

OF  WOMEN.  In  one  handsome  12mo.  volume  0f  368  pages  with 
107  illustrations.  Cloth,  $1.50,  net;  flexible  leather,  $2.00'  net 
Lea's  Series  ot  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet 
M.  D.     See  page  17. 

This  is,  like  all  the  other  manuals    book    for   practitioners.— St.  Louis 


in  this  series,  a  most  excellent  guide 
for  students  and  a  handy  reference 


Medical  and  Surgical  Journal. 


CROOK    (JAMES      K.)     ON    MINERAL     WATERS     OF     THE 
UNITED  STATES.     Octavo,  575  pages.     Cloth,  $3.50%* 
In  such  a  book  as  this  the  medical    of  every  water  of  any  known  medici- 
professron  will  find  a  wonderful  ally;    nal     properties.— The    Louisville 
it  is  remarkably  complete  in  every    Monthly  Journal 
detail,  giving  the  results  of  analyses 

CUIi?AI^™yPAyi:D  M  R)"    MATERIA  MEDICA  AND  PHAR- 

I  no        U(j*'     "New  (2d)  edltion-     In  one  handsome  octavo  volume 
of  881  pages,  with  464  illustrations.     Cloth,  $4.50,  net. 

CU^PN?L(A;Rr?H1JR  R°-   TEXT-BOOK  OF  PHARMACOLOGY. 

New  (2d)  ed.  Handsome  8vo.,  732  pp.,  with  47  illus.  Cloth,  $3.75,  net. 
The  best  exposition  of  our  knowl-  acqnaintingthemselves  with  the  verv 
edge  ot  pharmacology  which  has  yet  latest  knowledge  on  this  very  im- 
been  given  to  the  medical  public,  portant  subject.— The  Montreal  Med- 
We  can  cordially  recommend  it  to  ical  Journal. 
all  our  readers  who  are  desirous  of  \ 

DAMON  (JOHN  C).   A  TREATISE  ON  HUMAN  PHYSIOLOGY 

*ITein  +i,edl*011,     0ctavo>   722  PaSes>  with   252  engravings.     Cloth, 
<pt>  j  leatner,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In 


one  handsome  12mo.  volume  of  293  pages.     Cloth,  $2 

DAVENPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  of 
Gynecology.  For  the  use  of  Students  and  Practitioners.  New 
(3d)  edition,  m  one  handsome  12mo.  volume  of  387  pages  with  150 
illustrations.     Cloth,  $1.75,  net. 

Dr     Davenport    has    the    happy  knowing,  and  presents  these  princi- 

faculty  ot  selecting  just  those  points  pies  in  a  clear,  concise  and  thorough 

in  gynecological  therapeutics    and  manner.     The  book  can  be  highlv 

surgery  which  the  student  and  junior  commended.—  The  Medical  Aae 
practitioner  most  stand  in  need  of 

DAVIS  (EDWARD  P.).      A  TREATISE  ON  OBSTETRICS      FOR 

STUDENTS    AND    PRACTITIONERS.      In  one  verv    handsome 

octavo  volume  of  546  pages,  with  217   engravings  and  "30  full-page 

plates  in  colors  and  monochrome.    Cloth,  $5 ;  leather,  $6. 

From  a  practical  standpoint  the    thoroughly  scientific  and    brilliant 

work  is  all  that  could  be  desired.  A  |  treatise  on  obstetrics.  —Med.  News. 

DAVIS  (F.  H.).    LECTURES  ON  CLINICAL  MEDICINE.    Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.    In  one  large  octavo 
volume  of  700  pages,  with  300  engravings.     Cloth,  $4. 


8       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


DENNIS  (FREDERIC  S.)  AND  BILdDINGS  (JOHN  S.).  A  SYS- 
TEM OF  SURGERY.  In  contributions  by  American  Authors. 
Complete  work  in  four  very  handsome  octavo  volumes,  containing 
3652  pages,  with  1585  engravings  and  15  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cl  n,  $6.00;  leather,  $7.00;  half 
Morocco,  gilt  back  and  top,  $8.5  .  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  publishers. 
No  work  in  English  can  be  con-  I  American  Journal  of  the  Medical 

sidered  as  the  rival  of  this. — The  I  Sciences. 

DERCUM  (FRANCIS  X.,  EDITOR).  A  TEXT-BOOK  ON 
NERVOUS  DISEASES.  By  American  Authors.  In  one  handsome 
octavo  volume  of  1054  pages,  with  341  engravings  and  7  colored 
plates.     Cloth,  $6.00  ;  leather,  $7.00.    Net. 


The  best  text-book  in   any  lan- 
guage.— The  Medical  Fortnightly. 


The  most  thoroughly  up-to-date 
treatise  that  we  have  on  this  subject. 
— American  Journal  of  Insanity. 

DE  SCHWEINITZ  (GEORGE  E.).    THE  TOXIC  AMBLYOPIAS. 

Their  Classification,  History,  Symptoms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
plates  in  colors.     Limited  edition,  de  luxe  binding,  $4.     Net. 

DRAPER  ( JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT   ROBERT).    THE    PRINCIPLES   AND   PRACTICE  OF 

MODERN  SURGERY.  A  new  American,  from  the  twelfth  London 
edition,  edited  by  Stanley  Boyd,  F.  R.  C.  S.  In  one  large  octavo 
volume  of  965  pages,  with  373  engravings.     Cloth,  $4 ;  leather,  $5. 

DUANE  (ALEXANDER).  A  DICTIONARY  OF  MEDICINE  AND 
THE  ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Deriva- 
tion and  Full  Explanation  of  Medical,  Dental,  Pharmaceutical  and 
Veterinary  Terms.  Together  with  much  Collateral  Descriptive  Mat- 
ter. Numerous  Tables,  etc  New  (3d)  edition.  Square  octavo  of  652 
pages,  with  8  colored  plates,  witu  thumb  index.  Cloth,  $3.00,  net; 
limp  leather,  $4.00.,  net. 

DUDLTEY  (E.  C).  THE  PRINCIPLES  AND  PRACTICE  OF 
GYNECOLOGY.  New  (2d)  edition.  Handsome  octavo  of  717  pages, 
with  453  illustrations  in  black  and  colors,  and  8  colored  plates.  Cloth, 
$5.00,  net;  leather,  $6.00,  net;  half  Morocco,  $6.50,  net. 


tice  of  modern  gynecology .- 
national  Medical  Magazine. 


The   book    can  be   safely    recom-    tice  of  modern  gvnecologv. — Infer 
mended  as  a  complete  and  reliable 
exposition  of  the  principles  and  prac- 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE 
DISEASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.     Cloth,  $1.50. 

DUNHAM  (EDWARD    K.).       MORBID    AND    NORMAL     HIS- 
TOLOGY.    Octavo,  450  pages, with  363  illustrations.  Cloth,  $3.25,  net. 
The  best  one-volume  text  or  refer-  1  of  published  in  America. —  Virginia 
ence  book  on  histology  that  we  know  '  Medical  S>  mi-Monthly. 

NORMAL  HISTOLOGY.    New  (2d)  edition.     Octavo,  319  pages, 

with  244  illustrations.     Cloth,  $2.50,  net. 


Lea  Broth krk  &  Co.,  Philadelphia  and  New  York.       9 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  ROBLEY  DUNGLISON,  M.  D-,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  Edited 
by  Richard  J.  DUNGLISON,  A.  M .,  M.  D.  Twenty-second  edition,  thor- 
oughly revised  and  greatly  enlarged  and  improved,  with  the  Pronuncia- 
tion, Accentuation  and  Derivation  of  the  Terms.  With  Appendix. 
In  one  magnificent  imperial  octavo  volume  of  1350  pages,  with  thumb 
index.  Cloth,  $7.00,  Net;  leather,  $8.00,  Net.  This  edition  contains 
portrait  of  Dr.  Dunglison, 

The  most  satisfactory  and  authori-  scarcely  be  measured. — Med.  Record. 
tative  guide  to  the  derivation,  defini-        Pronunciation  is  indicated  bv  the 

tion  and   pronunciation   of  medical  phonetic  system.  The  definitions  are 

terms.— The  Charlotte  Med.  Journal,  unusually' clear  and  concise.    The 

Covering  the  entire  field  of  medi-  book  is   wholly   satisfactory. —  ZJni- 

cine,    surgery    and.  the     collateral  versity  Medical  Magazine. 
sciences,  its  range  of  usefulness  can 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND 
MATERIA  MEDICA.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50 ; 
leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.     Cloth,  $3  ;  leather.  $4. 

EGBERT  (SENECA).    A    MANUAL    OF   HYGIENE  AND  SANI- 
TATION.     New  (2d)  edition.     In  one  12mo.  volume  of  427  pages, 
with  77  illustrations.     Cloth,  Net,  $2.25. 
It  is   written  in  plain  language,  I  ligence.     The  writer  has  adapted  it 

and,  while  primarily  designed  for    to    American    conditions,   and    his 

physicians,  it  can  be  studied  with    suggestions  are,  above  all,  practical. 

profit  by  any  one  of  ordinary  intel-    — The  New  York  Medical  Journal. 

ELLIS  (GEORGE  VLNER).  DEMONSTRATIONS  IN  ANATOMY. 
Eighth  edition.  Octavo,  716  pages,  with  249  engravings.  Cloth, 
$4  25;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNECOLOGY.  Third  edition.  Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).   PROSTHETIC  DENTISTRY.  See  American 

Text-Books  of  Dentistry,  page  2. 

EVANS  (DAVID  J.).    A  POCKET  TEXT-BOOK  OF  OBSTETRICS. 

In  one  handsome  12mo.  volume  of  409  pages,  with  14S  illustrations. 
Just  ready.  Cloth,  $1.75,  Net;  limp  leather,  $2.25,  Net.  Lea's  Serifs 
of  Pocket  Text-books,  edited  by  Bern  B.  Gallai'det,  M.D.  See  p  17. 
EWING  (JAMES)  ON  THE  BLOOD  AND  ITS  DISEASES.  Hand- 
some octavo,  423  pages,  28  engravings,  14  colored  plates.  Just  ready. 
Cloth,  net,  $3.50. 


10     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


PARQUHARSON  (ROBERT).     A  GUIDE  TO  THERAPEUTICS, 

Fourth  American  from  fourth  English  edition,  revised  by  FRANK 
Woodbury,  M.  D.    In  one  12mo.  volume  of  581  pages.    ( !loth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  _  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FLINT  (AUSTIN).     A   TREATISE   ON    THE   PRINCIPLES  AND 

PRACTICE    OF   MEDICINE.     Seventh  edition,  thoroughly  revised 

by  Frederick  P.  Henry,  M.D.    In  one  large  8vo.  volume  of  1143 

pages,  with  engravings.     Cloth,  $5.00;  leather,  $6.00. 

The  work  has  well  earned  its  lead-        The  best  of  American  text-books 

ing  place  in   medical  literature.—    on  Practice. — Amer. Medico-Surgical 

Medical  Record.  \  Bulletin. 

A   MANUAL   OF   AUSCULTATION  AND  PERCUSSION;  of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson,  M.  D. 
In  one  handsome  12mo.  volume  of  274  pages,  with  12  engravings. 

A    PRACTICAL    TREATISE    ON    THE    DIAGNOSIS    AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  edition 
enlarged.     In  one  octavo  volume  of  550  pages.     Cloth,  $4. 

ON  PHTHISIS  :  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 


A  Series  of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages. 
Cloth,  $3.50. 

FOLSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S. 
ON  CUSTODY  OF  THE  INSANE.  In  one  8vo.  vol.  of  108  pages. 
Cloth,  $1.50.  With  Clouston  on  Mental  Diseases  (new  edition,  see 
page  6)  $5.00,  net,  for  the  two  works. 

FORMULARY,  POCKET,  see  page  32. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  Sixth 
and  revised  American  from  the  sixth  English  edition.  In  one  large 
octavo  volume  of  923  pp.,  with  257  illus.    Cloth,  $4.50 ;  leather,  $5.50. 


Unquestionably  the  best  book  that 
can  be  placed  in  the  student's  hands, 
and  as  a  work  of  reference  for  the 
busy  physician  it  can  scarcely  be 
excelled. — The  Phila.  Polyclinic. 


This  single  volume  contains  all 
that  will  be  necessary  in  a  college 
course,  and  all  that  the  physician 
will  need  as  well. — Dominion  Med. 
Monthly. 


FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75  ;  leather,  $4.75. 

POWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  In  one  royal 
12mo.  volume  of  1061  pages,  with  168  engravings,  and  1  colored 
plate.     Cloth,  $2.75  ;  leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.  R.).  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 

FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From  second  English  edition.  In  one  8vo.  volume  of  475 
ges.     Cloth,  $3.50. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.      11 


PULLER   (EUGENE).      DISORDERS    OF    THE    SEXUAL    OR- 
GANS   IN    THE    MALE.     In  one  very  handsome  octavo  volume  of 
with    25   engravings  and   8  full-page  plates.      Cloth 


It  is  an  interesting  work,  and  one 
which  is  timely  and  needed. — Medi- 
cal Fortnightly. 

The  book  is  valuable  and  instruc- 
tive   and    brings    views     of   sound 


pathology  and  rational  treatment  to 
many  cases  of  sexual  disturbance 
whose  treatment  has  been  too  often 
fruitless  for  good.  —  Annals  of 
Surgery. 


GALLAUDET  (BERN  B.).  A  POCKET  TEXT-BOOK  OX  SUR- 
'  I E  RY.  In  one  handsome  12nio.  volume  of  about  400  pages,  with  many 
illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books,  edited  by 
Bern  B.  Gallaidet,  M.  D.     See  page  17. 

GAXT  FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3.75. 

GAYLORD  (HARVEY  R.).  AX  ATLAS  OF  PATHOLOGICAL 
ANATOMY.  325  pages,  70  engravings  and  29  full-page  heliotype 
plates  in  colors  and  black.     In  Press. 

GERRISH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY. 
By  American  Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.  In  one 
imp.  octavo  volume  of  915  pages,  with  950  illustrations  in  black  and 
colors.  Cloth,  $6.50;  flexible  waterproof,  $7;  leather,  $7.50,  net; 
half  Morocco,  $8.00,  net. 


with  less  waste  of  words  and  better 
empha&is  of  important  points  than 
any  similar  text-book  with  which 
we  are  familiar. — The  Boston  Medi- 
cal and  Surgical  Journal. 

TVe  believe  that  this  volume  not 
only  takes  rank  with  all  other  works 
on  anatomy,  but  in  some  respects  is 
superior  to  any  now  available. — The 
Chicago  Jledical  Recorder. 


The  illustrations  far  outnumber 
and  exceed  in  size  and  in  profusion 
of  colors  those  in  any  previous  work  ; 
and  they  can  well  claim  to  be  the 
most  successful  series  of  anatomical 
pictures  in  the  world. — The  Ameri- 
can Practitioner  and  News. 

The  chief  merit  in  the  book  will 
be  found  in  the  descriptive  text, 
which  is  accurate,  concise,  and  gives 
the  essentials  of  descriptive  anatomy 

GD3BES  (HEXEAGE).  PRACTICAL  PATHOLOGY  AXD  MORBID 

HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.    Cloth,  $2.75. 

GRAY(HEXRY).    ANATOMY,  DESCRIPTIVE  AXD  SURGICAL. 

Xew  and  thoroughly  revised  American  edition,  much  enlarged  in  text, 
and  in  engravings  in  black  and  colors.  In  one  imperial  octavo  volume 
of  1239  pages,  with  772  large  and  elaborate  engravings  on  wood.  Price 
of  edition  with  illustrations  in  colors  :  cloth,  $7 ;  leather,  $8.  Price 
of  edition  with  illustrations  in  black :  cloth,  $6 ;  leather,  $7. 

This    is    the  best  single  volume       Gray' $  Anatomy  affords  the  student 
upon    Anatomv     in     the     English    more    satisfaction    than    any  other 


language. —  University  Jledical  Mag- 
azine. 

Gray's  Anatomy  should  be  the 
first  work  which  a  medical  student 
should  purchase,  nor  should  he  be 
without  a  copy  tb  rough  out  his  pro- 
fessional career. — Pittsburg  Medical 
Review. 


treatise  with  which  we  are  familiar. 
— Buffalo  Med.  Journal. 

The  most  largely  used  anatomical 
text-book  published  in  the  English 
language. — Annals  of  Surgery. 

Holds  first  place  in  the  esteem  of 
both  teachers  and  students. —  The 
Brooklyn  Medical  Journal. 


12      Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.     <  Jloth,  $2.  Sec  Student's  Scries  of  Manuals ,  p.  27. 

GREEN  (T.HENRY).  PATHOLOGY  AND  MORBID  ANATOMY 
New  (9th)  American  from  the  ninth  London  edition.  In  one  hand- 
some octavo  volume  of  577  pages,  with  339  engravings  and  4  colored 
plates.     Cloth,  $3.25,  net. 


A  work  that  is  the  text-book  of 
probably  four-fifths  of  all  the  stu- 
dents of  pathology  in  the  United 
States  and  Great  Britain. — The 
American  Practitioner  and  News. 


The  work  is  an  essential  to  the 
practitioner — whether  as  surgeon  or 
physician.  It  is  the  best  of  up-to- 
date  text-books. —  Virginia  Medical 
Monthly. 

GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry.     In  one  12mo.  vol.  of  310  pages,  with  74  illus.    Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GRINDON  (JOSEPH).  A  POCKET  TEXT-BOOK  OF  SKIN 
DISEASES.  In  one  handsome  12mo.  volume  of  350  pages,  with 
many  illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books,  edited 
by  Bern  B.  Gallattdet,  M.  D.     See  page  17. 

HABERSHON  (S.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN 
Second  American  from  the  third  English  edition.  In  one  octavo  vol- 
ume of  554  pages,  with  11  engravings.     Cloth,  $3.50. 

HALL  (WINFIELD  S.).  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
of  672  pages,  with  343  engravings,  and  6  full  page  colored  plates. 
Cloth,  $4.00  ;   leather,  $5.00,  net. 


of  which  needs  to  be  more  strongly 
impressed  upon  students  A  book 
which  makes  this  so  easily  possible 
is  to  be  highly  commended. —  West- 
ern Medical  Review. 


Truly  a  scientific  treatment  of  the 
subject.  The  clearness  with  which 
physiological  facts  are  demonstrated 
makes  it  of  special  value  to  the 
medical  student.  The  science  of 
physiology  is  one,  the  importance 

HAMILTON  (ALLAN  MCLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 

HARD  A  WAY  ( W.  A.).  MANUAL  OF  SKIN  DISEASES.  New  (2d) 
edition.  In  one  12mo.  volume  of  560  pages,  with  40  illustrations  and 
2  plates.     Cloth,  $2.25,  net. 


The  best  of  all  the  small  books  to 
recommend  to  students  and  practi- 
tioners. Probably  no  one  of  our 
dermatologists  has  had  a  wider  every- 


day clinical  experience.  His  great 
strength  is  in  diagnosis,  descriptions 
of  lesions  and  especially  in  treat- 
ment.— Indiana  Medical  Journal. 


HARE  (HOBART  AMORY)     ON  THE   MEDICAL   COMPLICA- 
TIONS AND    SEQUELS  OF  TYPHOID   FEVER.      Octavo,  276 
pages,  21  engravings   and  two  full-page  plates.     Cloth,  $2.40,  net. 
A  very  valuable  production.    One  I  read  with   great  profit. —  Cleveland. 

of  the  very   best   products  of   Dr.    Journal  of  Medicine. 

Hare  and  one  that  every  man  can  ' 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     13 


IIAUH  (HOBART  AMOUYi.  PRACTICAL  DIAGNOSIS.  THE 
USE  OF  SYMPTOMS  IN  THE  DIAGNOSIS  OF  DISEASE.  Fourth 
edition.  Jm  one  octavo  volume  of  623  pages,  with  205  engravings 
and  14  full-page  colored  plates.  Cloth,  $5.00,  net;  half  Morocco, 
$6.50,  net. 


It  is  unique  in  many  respects,  and 
the  author  lias  introduced  radical 
chauges  which  will  be  welcomed  by 
all.  Anyone  who  reads  this  book 
will  become  a  more  acute  observer, 
will  pay  more  attention  to  the  simple 
yet  indicative  signs  of  disease,  and 


lie  will  become  a  better  diagnosti- 
cian. This  is  a  companion  to  Prac- 
tical Therapeutics,  by  the  same 
author,  and  it  is  difficult  to  conceive 
of  any  two  works  of"  greater  practical 
utility. — Meddcal  Review. 


HARE  (HOB ART  AMORY).     A    TEXT-BOOK   OF  PRACTICAL 

THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
Eighth  and  revised  edition.  In  one  octavo  volume  of  796  pages, 
with  37  engravings  and  3  colored  plates.  Cloth,  $4.00,  net;  leather, 
$5.00,  net;  half  Morocco,  $5.50,  net. 


Its  classifications  are  inimitable, 
and  the  readiness  with  which  any- 
thing can  be  found  is  the  most  won- 
derful achievement  of  the  art  of  in- 
dexing. This  edition  takes  in  all 
the  latest  discovered  remedies. — 
The  St.  Louis  Clinique. 

The  great  value  of  the  work  lies 
in  the  fact  that  precise  indications 
for  administration  are  given.  A 
complete  index  of  diseases  and 
remedies  makes  it  an  easy  reference 
work.    It  has  been  arranged  so  that 


it  can  be  readily  used  in  connection 
with  Hare's  Practical  Diagnosis. 
For  the  needs  of  the  student  and 
general  practitioner  it  has  no  equal. 
— Medica  1  Sent  in  el. 

The  best  planned  therapeutic  work 
of  the  century. — American  Prac- 
titioner and  News. 

It  is  a  book  precisely  adapted  to 

the  needs  of  the  busy  practitioner, 

who  can  rely  upon  finding  exactly 

what  he  needs. — The  National  Med- 

,  ical  Review. 


HARE'S  SYSTEM  OF  PRACTICAL  THERAPEUTICS.  In  a  series 
of  contributions  by  eminent  practitioners.  ^New  (2d)  edition.  Just 
ready.  In  three  large  octavo  volumes  containing  2593  pages,  with 
457  engravings  and  26  full-page  plates.  Price  per  volume,  cloth, 
$5.00;  leather,  $6.00;  half  morocco,  S7.00.  Full  prospectus  free  on 
application.     For  sale  by  subscription  only. 


The  Hare's  System  of  ten  years 
ago  will  hardly  be  recognized  in 
this  new  edition,  so  complete  are  the 
changes,  so  extended  the  disserta- 
tion and  so  complete  the  re-dress. 
The  additions  alone  are  sufficient  to 
make  a  new  volume.  The  choice  of 
subjects  is  wide  and  the  names  of 
the  authors  are  a  sufficient  guaran- 
tee of  the  character  of  the  mode  of 
treatment.  The  dominant  feature 
of   the    work,  one    that    the    well- 


known  editor  constantly  presents,  is 
the  every  day  workability  of  treat- 
ments advocated.  Here  are  no 
thy  theoretical  dissertations 
largely  padded  by  quotations  from 
European  authors,  but  concise,  prac- 
tical rules  that  can  be  made  to  fit 
present-day  needs.  What,  why 
and  how  are  the  questions  with  ref- 
erence to  the  use  of  drugs  that  the 
authors  answer  —  particularly  the 
hqw. — Medical  News. 


14     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

HARRINGTON  (CHARLES).  PRACTICAL  HYGIENE.  Hand- 
some octavo,  721  pages,  105  engravings,  12  plates.  Just  ready. 
Net,  $4.25. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  Avith  144  engravings.     Cloth,  $2.75. 


A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 

12mo.  volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery  and  Obstetrics.  Second  edition.  In  one  royal 
12mo.  vol.  of  1028  pages,  with  477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  (JAMES  R.).    A  MANUAL  OF  VENEREAL  DISEASES. 

Second  edition.  In  one  12mo.  volume  of  304  pages,  with  54  en- 
gravings.    Cloth,  $1.50,  net. 

It  is  practical,  concise,  definite 
and  of  sufficient  fulness  to  be  satis- 
factory.—  Chicago   Clinical  Review. 


It  is  well  written,  up  to  date,  and 
will  be  found  very  useful. — Inter- 
national Medical  Magazine. 


HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Waters.  Edited  by  Prof.  H.  A.  Hare,  M.  D.  In  one  octavo  volume 
of  414  pages,with  113  engravings.     Cloth,  $3. 


HERMAN  (G.  ERNEST).     FIRST  LINES  IN  MIDWIFERY.     In 

one  12mo.  vol.  of  198  pages,  with  80  engravings.     Cloth,  $1.25.     See 
Student's  Series  of  Manuals,  page  27. 

HERMANN  (L..).  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).     A  HANDBOOK   OF   DIAGNOSIS.     In 

one  handsome  12mo.  volume  of  429  pages,  with  80  engravings  and  2 
colored  plates.     Cloth,  $2.50. 

We  commend  the  book  not  only  to  Excellently    arranged,    practical, 

the  undergraduate,  but  also  to  the  concise,   up-to-date,   and  eminently 

physician  who  desires  a  ready  means  well  fitted  for  the  use  of  the  prac- 

of  refreshing  his  knowledge  of  diag-  titioner  as  well  as  of  the  student. — 

nosis  in  the  exigencies  of  professional  Chicago  Med.  Recorder. 
life. — Memphis  Medical  Monthly. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     15 


HILL.  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.     In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HILLIEK  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.  .  HUMAN 

MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Limited  edition.  For  sale 
by  subscription  only. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS 
USED  IN   MEDICINE   AND   THE  COLLATERAL  SCIENCES. 

New  (13th)  edition.  In  one  12mo.  volume  of  845  pages.  Cloth, 
$3.00,  net. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN, 
INCLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  vol.  of  519  pp.,  'with  illus.     Cloth,  $4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.). 

A  MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the 
Examination  of  Medicinal  Chemicals  and  their  Preparations.  Third 
edition,  entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  A  new  American  from  the  fifth  English  edition. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  In  one  handsome  octavo  vol- 
ume of  1008  pages,  with  428  engravings.     Cloth,  $6 ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.  With  notes  and  additions  by  various 


American  authors.  Edited  by  John  H.  Packard,  M.  D.  In  three 
very  handsome  8vo.  volumes  containing  3137  double-columned  pages, 
with  979  engravings  and  13  lithographic  plates.  Per  volume,  cloth,  $6  ; 
leather,  $7 ;  half  Russia,  $7.50.    For  sale  by  mbucriptwn  only. 

HORNER  (WILLIAM  E.).  SPECIAL  ANATOMY  AND  HIS- 
TOLOGY. Eighth  edition,  revised  and  modified.  In  two  large  8vo. 
volumes  of  1007  pages,  containing  320  engravings.    Cloth,  $6. 

HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one 
octavo  volume  of  308  pages.     Cloth,  $2.50. 

HUNTINGTON  (GEORGE  S.).  A  TREATISE  ON  ABDOMINAL 
ANATOMY.  Imperial  octavo,  with  250  pages  of  text  and  250  full- 
page  plates.     Shortly. 


16     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

HYDE  (JAMES  NEVINS).     A  PRACTICAL  TREATISE  ON  DIS- 
EASES OF  THE   SKIN.     New   (6th)   edition,  thoroughly  revised. 
Octavo,  832  pages,  with  107  engravings  and  27  full-page  plates,  9  of 
which  are  colored.  Justready.   Cloth,  $4.50, net;    leather,  $5.50,  net ; 
half  Morocco,  $6.00,  net. 
This  edition  has  been  carefully  re- 1  culcated  throughout  is  sound  as  well 
vised,   and  every  real  advance  has  J  as  practical. — The  American  Jour- 
been  recogoized.     The  work  answers  j  nal  of  the  Medical  Sciences. 
the  needs  of  the  general  practitioner,  [      jt  [s   t^e   hest    one- volume  work 
the  specialist,  and  the  student.— The    that  we  know.—  Virginia  Medical 
Ohio  Med.  Jour.  Semi-Monthly. 

A  treatise  of  exceptional    merit  |      A   full  and  thoroughly    modern 
characterized  by  conscientious  care    text-book    on     dermatology.  —  The 


and    scientific    accuracy. — Buffalo 
Med.  Journal, 

A    complete     exposition    of    our 


Pittsburg  Medical  It e new. 

The  most  practical  handbook  on 
derrnatolocrv  with  which  we  are  ac- 


knowledge of  cutaneous  medicine  as  i  quainted.  —  Chicago     Medical    Re- 
it  exists  to-day.     The  teaching  in- )  corder. 

JACKSON  (GEORGE  THOMAS).  THE  READY-REFERENCE 
HANDBOOK  OF  DISEASES  OF  THE  SKIN.  Third  edition. 
In  one  12mo.  volume  of  637  pages,  with  75  illustrations  and  a  colored 
plate.     Cloth,  $2.50,  net. 

As  a  student's  manual,  it  may  be  Without  doubt  forms  one  of  the 
considered  beyond  criticism.  The  best  guides  for  the  beginner  in  der- 
book  is  singularly  full.—  St.  Louis  ,  matology  that  is  to  be  found  in  the 
Medical  and  Surgical  Journal.  English  language. — Medicine. 

JAMIESON  (W.  ALLAN).     DISEASES    OF    THE    SKIN.      Third 

edition.     In  one  octavo  volume  of  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographic  plates.    Cloth,  $6. 

JEWETT   (CHARLES).  ESSENTIALS  OF   OBSTETRICS.     In  one 
12mo.  volume  of  356  pages,  with  80  engravings  and  3  colored  plates. 
Cloth,  $2.25. 
An  exceedingly  useful  manual  for  I  ing  it  in  attractive  and  easily  tangi- 

student  and  practitioner.     The  au-  ;  ble  form.     The  book  is  well  illus- 

thor  has  succeeded  unusually  well    trated  throughout. — Nashville  Jour. 

in  condensing  the  text  and  in  arrang-  |  of  Medicine  and  Surgery. 

-  THE  PRACTICE  OF  OBSTETRICS.     By   American    Authors. 


One  large  octavo  volume  of  763  pages,  with  441  engravings  in  black 

and    colors,    and    22    full-page   colored   plates.      Cloth,   $5.00,  net ; 

leather,  $6.00,  net;  half  Morocco,  80.50,  net. 

A  clear  and  practical  treatise  upon    the  book    abounds.      The  work  is 

obstetrics  by  well-known  teachers  of   sure  to  be  popular    with    medical 

the  subject.     A  special    feature   of   students,  as  well  as  being  of  extreme 

this  work  would   seem    to    be   the    value  to    the    practitioner.  —  The 

excellent  illustrations    with   which    Medical  Age. 

JONES  (C.  HANDF1ELD).  CLINICAL  OBSERVATIONS  ON 
FUNCTIONAL  NERVOUS  DISORDERS.  Second  American  edi- 
tion.    In  one  octavo  volume  of  340  pages.     Cloth,  $3.25. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     17 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.  Second  edition.  In  one  octavo  volume  of  549 
pages,  with  201  engravings,  17  chromo-lithosrraphic  plates,  test-types  of 
Jaeger  and  Snellen,  and  Holmgren's  Color-Blindness  Test.  "Cloth, 
$5.50 ;  leather,  $6.50. 

The  volume  is  particularly  rich  in    color  blindness,   etc.    The    sections 
matter  of   practical  value,   such   as    devoted  to  treatment  are  singularly 
directions    for    diagnosing,    use    of   full  and  concise. — Medical  Age,. 
instruments,  testing  for  glasses,  for  ! 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Eighth  edition. 
In  one  12mo.  volume  of  612  pages,  with  26-4  illustrations.  Cloth, 
$2.50,  net. 

From  first  to  finish  it  is  thoroughly  cyclopedias.        The     well-arranged 

practical,  concise  in  expression,  well  index    renders  the   book  useful  to 

illustrated,  and  includes  a  statement  the  practitioner  who  is  in  haste  to 

of  nearly  every  fact  of  importance  refresh     his     memoiy.  —   Virginia 

discussed  in    obstetric    treatises   or  Medical  Semi-Monthly. 

KIRK   (EDWARD    C).      OPERATIVE    DENTISTRY.     New  (2d) 

edition.    Handsome  octavo  of  857  pages,  with  897  illustrations.     See 

American  Text-Books  of  Dentistry,  page  2. 
"Wehave  only  the  highest  praise    tempted.     We  can  heartily  recom- 
for  this  valuable  work.   It  is  replete    mend    it    to    the    profession. — The 
in  every  particular,  and  surpasses    Ohio  Dental  Journal. 
anything  of  the  kind  heretofore  at-  J 

KLEIN  (E.).    ELEMENTS  OF  HISTOLOGY.     New  (5th)  edition.   In 
one   12mo.  volume  of  506  pages,  with  296  engravings.     Cloth,  $2.00, 
net.     See  Student's  Series  of  Manuals,  page  27. 
_  It  is  the  most  complete  and  Gon-        This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has  yet    first  place  as  a  text-book  on   his- 

emanated  from  the  press.— TheMed-    tology. —  Canadian  Practitioner. 

ical  Age. 

LANDIS  (HENRY  G.).   THE  MANAGEMENT  OF  LABOR.   In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.    Cloth,  $1.75. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY- 
BOOK  OF  OPHTHALMIC  SURGERY.  Second  edition.  In  one 
octavo  volume  of  227  pages,  with  66  engravings.     Cloth,  $2.75. 

LEAS  SERIES  OF  POCKET  TEXT-BOOKS,  edited  bv  Been 
B.  Gallatjdet,  M.  D.  Covering  the  entire  field  of  Medicine  in  a 
series  of  16  very  handsome  12mo.  volumes  of  350-450  pages  each, 
profusely  illustrated.  Compendious,  clear,  trustworthy  and'modern. 
The  following  volumes  constitute  the  series. 

Coates'  Bacteriology.  Collins'  Anatomy.  Collixs  and  Rock- 
well's Physiology.  Maettx  and  Rockwell's  Chemistrv  and 
Physics.  Nichols  and  Vale's  Histology  and  Patliologv. 
Schleif's  Materia  Medica,  Therapeutics,  Medical  Latin,  etc.  Mals- 
bary's  Practice  of  Medicine.  Collixs'  Diagnosis.  Potts'  Nervous 
and  Mental  Diseases.  Gallatjdet's  Surgerv.  Geixdox's  Der- 
matology. Ballexgee  and  Wippeex's  Diseases  of  the  Eve,  Ear, 
Throat  and  Nose.  Evans'  Obstetrics.  Ceockett's  Gynecology. 
Tuttle's  Diseases  of  Children. 

For  separate  notices  see  under  various  authors'  names. 


18     Lea  Brothees  &  Co.,  Philadelphia  and  New  York. 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.    Per  volume,  cloth,  $3.00. 

CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN ; 

CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI- 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA ; 
BRIANDA  DE   BARDAXI.     12mo.,  522  pages.     Cloth,  $2.50. 


—  THE  MORISCOS  OF  SPAIN,  THEIR  CONVERSION  AND 
EXPULSION.    In  one  royal  12mo.    volume  of  425  pages.      Just 

ready.     Cloth,  $2.25,  net. 

—  SUPERSTITION  AND  FORCE ;  ESSAYS  ON  THE  WAGER 
OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 

—  STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Temporal 
Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.     Cloth,  $2.50. 

—  AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.  Second  edition.  In  one  hand- 
some octavo  volume  of  685  pages.     Cloth,  $4.50. 

LOOMIS     (ALFRED    L.)    AND   THOMPSON    (W.    GDLMAN, 

EDITORS).  A  SYSTEM  OF  PRACTICAL  MEDICINE.  In 
Contributions  by  Various  American  Authors.  In  four  very  hand- 
some octavo  volumes  of  about  900  pages  each,  fully  illustrated  in 
in  black  and  colors.  Complete  work  now  ready.  Per  volume,  cloth, 
$5 ;  leather,  $6  ;  half  Morocco,  $7.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  Publishers.  See  American 
System  of  Practical  Medicine,  page  2. 

LYMAN  (HENRY  M.).    THE  PRACTICE  OF  MEDICINE.    In  one 

very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $4.75 ;  leather,  $5.75. 


Complete,  concise,  fully  abreast  of 
the  times  and  needed  by  all  students 
and  practitioners. —  Univ.  Med.  Mag. 


An  exceedingly  valuable  text-book. 
Practical,  systematic,  and  well  bal- 
anced.— Chicago  Med.  Recorder. 


LYONS  (ROBERT  D.).     A  TREATISE  ON  FEVER.    In  one  octavo 
volume  of  362  pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  ON  THE  NOSE  AND  THROAT. 

Handsome  octavo,  about  600  pages,  richly  illustrated.     Preparing. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     19 

MA1SCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA 
M  KDICA.  Seventh  edition,  thoroughly  revised  by  H.  C.  C.  MAISCH, 
Ph.  G.,  Ph.  D.  In  one  very  handsome  12mo.  volume  of  512  pages,  with 
285  engravings.     Cloth,  $2.50,  net. 

Used  as  text-book  in  every  college  '  in  America.  The  work  has  no  equal, 
of  pharmacy  in   the  United   States  !  — Dominion  Med.  Monthly. 
and  recommended   in   medical   col-       The    best  handbook    upc/n  phar- 
leges. — American  Therapist.  macognosy  of  any  published  in  this 

Noted  on  both  sides  of  the  Atlantic  country. — Boston  Med.  &  Sur.  Jonr. 
and  esteemed  as  much  in  Germany  as  I 

MALSBARY  (GEORGE  E.).  A  POCKET  TEXT-BOOK  OF 
THEORY  AND  PRACTICE  OF  MEDICINE.  In  one  handsome 
12mo.  volume  of  405  pages,  with  45  illustrations.  Cloth,  $1.75,  net; 
flexible  red  leather,  $2.25,  net.  Lea's  Series  of  Pocket  Text-books, 
edited  by  Berx  B.  Gallattdet,  M.  D.    See  page  17. 

Will  readily  commend  itself  to  !  deals  briefly  and  systematically  with 
students  and  busy  practitioners,  j  each  disease,  as  to  its  history,  retiol- 
bringing  forward  as  it  does  the  most !  ogy,  symptomatology,  diagnosis, 
recent  advances  in  medicine  with  prognosis  and  treatment. — Medical 
the  best  of  that  which  is  old.    It  i  Revieiv  of  Reviews. 

MANTJAJLS.  See  Student's  Quiz  Series,  page  27,  Student's  Series  of 
Manuals,  page  27,  and  Series  of  Clinical  Manuals,  page  25. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

MARTIN  (EDWARD).    A  MANUAL  OF  SURGICAL  DIAGNOSIS. 

In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.     Preparing. 

MARTIN  (WALTON)  AND  ROCKWELL  (WM.  H).    A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  PHYSICS.    In  one  hand- 
some 12mo.  volume  of  366  pages,  with  137  illustrations.     Cloth,  $1.50, 
net;    limp  leather,  $2.00,  net.      Lea's  Series  of  Pocket   Text-Books, 
edited  by  Bern  B.  Gallattdet,  M.  D.      See  page  17. 
Contains   everything   of   the  sci-    rately  reflects  both  sciences  in  their 
ences    of   chemistry    and    physics    present  development.     The  arrange- 
necessary  for  the  medical   student    ment  of  the  matter  is  excellent. — 
and  practitioner.     The  work  accu-    The  Medical  and  Surgical  monitor. 

MAY  (C.  H.).  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For 
the  use  of  Students  and  Practitioners.  Second  edition,  revised  by  L. 
S.  Ratj,  M.  D.  In  one  12mo.  volume  of  360  pages,  with  31  engrav- 
ings.    Cloth,  $1.75. 

MEDICAL  NEWS  POCKET  FORMULARY,  see  page  32. 


20 


Lea  Beothers  &  Co.,  Philadelphia  and  New  York. 


MITCHELL.  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS 
DISEASES.  In  one  12mo.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.     Cloth,  $2.50. 

The  book  treats  of  hysteria,  recur- 
rent melancholia,  disorders  of  sleep, 
choreic  movements,  false  sensations 


contractions,  rotary  movements  in 
the  feeble  minded,  etc.  Few  can 
speak  with  more  authority  than  the 
author. —  The  Journal  of  the  Ameri- 
can Medical  Association. 


of  cold,  ataxia,  hemiplegic  pain, 
treatment  of  sciatica,  erythromelal- 
gia,  reflex  ocularneurosis,  hysteric 

MITCHELL   (JOHN  K.).     REMOTE    CONSEQUENCES    OF    IN- 
JURIES   OF    NERVES    AND    THEIR    TREATMENT.     In  one 

handsome  12mo.  volume  of  239  pages,with  12  illustrations.  Cloth,  $1.75. 


MORRIS    (MALCOLM).      DISEASES    OF   THE    SKIN.      Second 
edition.     In  one  12mo.  volume  of  601  pages,  with  10   chromo-litho- 
graphic  plates  and  26    engravings.     Cloth,  $3.25,   net. 
The  work  is  essentially  clinical    strong  common  sense.     It  is  alike 


and  practical  in  its  scope  and  is 
characterized  throughout  by  clear- 
ness   and    simplicity  of   style   and 


suitable  for  the  student,  physician 
and  specialist.  —  Buffalo  Medical 
Journal. 


MULLER  (J.).    PRINCIPLES   OF   PHYSICS   AND  METEOROL- 
OGY.   In  one  large  8vo.  vol.  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 


MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL 
DIAGNOSIS,  for  Students  and  Physicians.  New  (4th)  edition,  thor- 
oughly revised.  In  one  octavo  volume  of  1104  pages,  with  250  en- 
gravings and  49  full-page  colored  plates.  Cloth,  $6.00,  net;  leather, 
$7.00,  net;  half  Morocco,  $7.50,  net. 


We  have  no  work  of  equal  value 
in  English.  —  University  Medical 
Magazine. 

From  its  pages  may  be  made  the 
diagnosis  of  every  malady  that 
afflicts  the  human  body,  including 
those  which  in  general  are  dealt 
with  only  by  the  specialist. — North- 
tvestern  Lancet. 


It  so  thoroughly  meets  the  precise 
demands  incident  to  modern  research 
that  it  has  been  adopted  as  the  lead- 
ing text-book  by  the  medical  colleges 
of  this  country. — North  American 
Practitioner. 

The  best  of  its  kind,  invaluable  to 
the  student,  general  practitioner  and 
teacher. — Montreal  Medical  Journal. 


NATIONAL  DISPENSATORY.  See  StilU,  Maisch  &  Caspari,  p.  27. 

NATIONAL  FORMULARY.    See  Stille,  Maisch  &  CasparVs  National 
Dispensatory,  page  27. 


NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  page  4. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     21 

NETTLESHIP(E.  .  DISEASES  OF  THE  EYE.  New  (6th)  American 
from  sixth  English  edition,  thoroughly  revised.  Jn  our  12mo.  volume 
of  562  pages,  with   192  engravings,  and  5  colored  plates,  test-types, 

formulae  and  color-blindness  test.     Cloth,  $2.25,  net. 

By  far  the  best  student's  text-book  I  The  present  edition  is  the  result 
on  the  subject  of  ophthalmology.—  of  revision  both  in  England  and 
The  Clinical  Review.  America,  and  therefore  contains  the 

This  work  for  compactness,  practi-    ^test    and    best    ophthalmologic 
cality  and  clearness  has  no  superior    1(?eas  of  *>?£  continents.- The  Phy- 
in  the  English  language.- Journal   ™wn  and  Surgeon, 
of  Medicine  and  Science.  I 

NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT- 
BOOK OF  HISTOLOGY  AND  PATHOLOGY.  In  one  handsome 
12mo.  volume  of  452  pages,  with  213  illustrations.  Cloth,  $1.75,  net: 
flexible  red  leather,  $2.25,  net. 

Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet, 
M.  D.     See  page  17. 

So  systematically  arranged  that  it  can  safelv  and  conscientiously  ree- 
ls, in  the  highest  degree,  interesting,  ommend  'it  to  both  students  and 
Thoroughly  up  to  date.  The  book  practitioners.— The  St.  Louis  Medi- 
is  an  exceptionally  good  one.     We  cal  and  Surgical  Journal. 

NOKRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5 ;  leather,  $6. 

It  is  practical  in   its   teachings.  ;  has  ever  been  offered  to  the  Arner- 
We  unreservedly  endorse  it  as  the    ican    medical    public— Annals    of 
best,  the  safest  and  the  most  compre-    Ophthalmology  and  Otology. 
hensive  volume  upon  the  subject  that  j 

OWEN    (EDMUND).      SUKGICAL    DISEASES    OF    CHILDREN. 

In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 

PARK  (ROSWELL).  A  TREATISE  ON  SURGERY  BY  AMERI- 
CAN AUTHORS.  Condensed  edition.  In  one  royal  octavo  volume 
of  1261  pages,  with  625  engravings  and  37  full-page  plates.  Cloth, 
$6.00,  net ;  leather,  $7.00,  net. 

The  work  is  fresh,  clear  and  practi-    clear-cut,  thoroughlv    modern  -and 
cal,  covering  the  ground  thoroughly    admirably  resourceful.— Johns  Hop- 
yet  briefly,  and  well  arranged  for  ■kins  Hospital  Bulletin. 
rapid  reference,  so  that  it  will  be  of       The  latest  and  best  work  written 
special  value  to  the  student  and  busy    upon  the  science  and  art  of  surgery 
practitioner.       The     pathology     is    Columbus  Medical  Journal. 
broad,  clear  and  scientific,  while  the  ,      It  is  thoroughly  practical  and  yet 
suggestions     upon     treatment     are  ,  thoroughly  scientific— Med.  News 


22     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

PARK  (WILL.IAM  H.).     BACTERIOLOGY  IN  MEDICINE  AND 

SURGERY.     12mo.,  688  pages,  with  87  illustrations  in   black  and 
colors,  and  2  plates.     Cloth,  $3.00  net. 


This  book  fills  a  very  distinct 
gap.  None  of  the  text-books  in  our 
language  take  up  the  subject  of  bac- 
teriology so  thoroughly  and  so 
soundly  as  does  this  from  the  point 


of  view  of  the  hygienist  and  public 
health  officer.  The  work  is  correct 
and  very  well  up  to  date. — The  Mon- 
treal Medical  Journal. 


PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS 
CLINICAL  HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.   In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 


PARVIN  (THEOPHILUS).    THE  SCIENCE  AND  ART  OF  OB- 
STETRICS.     Third  edition.      In  one  handsome  octavo  volume  of 
677  pages,  with  267  engravings  and  2  colored  plates.      Cloth,  $4.25 ; 
leather,  $5.25. 
Parvin's  work   is  practical,  con-    English  language. — Medical    Fort- 


cise  and  comprehensive.     We  com- 
mend it  as  first  of  its  class  in  the 


nightly. 


PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  3. 

PEPPER  (A.  J.).     FORENSIC  MEDICINE.    In  press..  Sen  Student1* 

Series  of  Manuals,  page  27. 

SURGICAL  PATHOLOGY.     In  one  12mo.  volume  of  511  pages, 


with  81  engravings.   Cloth,  $2.   See  Student's  Series  of  Manuals,  p.  27 

PICK  (T.  PICKERING).      FRACTURES  AND  DISLOCATIONS. 

In  one  12mo.  volume  of  530  pages,  with  93  engravings.      Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

PL.AYFAIR  (W.   S.).     A  TREATISE  ON    THE  SCIENCE   AND 
PRACTICE  OF  MIDWIFERY.     Seventh  American  from  the  ninth 
English  edition.     In  one  octavo  volume  of  700    pages,    with    207 
engravings  and  7  plates.     Cloth,  $3.75  net ;  leather,  $4.75,  net. 
An   epitome  of  the  science    and    a  safe  guide  to  both  student  and 


practice  of  midwifery,   which  em 
bodies  all  recent  advances.  —  The 
Medical  Fortnightly. 

This  work  must  occupy  a  fore- 
most place  in  obstetric  medicine  as 


obstetrician.  It  holds  a  place  among 
the  ablest  English-speaking  authori- 
ties on  the  obstetric  art. — Buffalo 
Medical  and  Surgical  Journal. 


—  THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRA- 
TION AND  HYSTERIA.  In  one  12mo.  volume  of  97  pages 
Cloth,  $1. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     23 


POCKET   FORMULARY,  see  page  32. 

POCKET  TEXT-BOOKS,  see  page  18. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
EAR  AND  ADJACENT  ORGANS.  Second  American  from  the 
third  German  edition.  Translated  by  Oscar  Dodd,  M.  D.,  and 
edited  by  Sir  William  Dalby,  F.  R.  C.  S.  In  one  octavo  volume  of 
748  pages,  with  330  original  engravings. 

POTTS  (CHARLES  S.j.  A  POCKET  TEXT-BOOK  OF  NERVOUS 
AND  MENTAL  DISEASES.  In  one  handsome  12mo.  volume  of 
445  pages,  with  88  engravings.  Cloth,  $1.75,  net;  limp  leather,  $2.25, 
net.  Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallau- 
det,  M.  D.     See  page  17. 

Dr.  Potts  has  succeeded  in  de-  of  the  numerous  discoveries  in  every 

picting  the  main  facts  in  a  manner  branch  of  neurology  is  clearly  pre- 

that  will  be  appreciated  by  students  sented.  The  book  is  a  reliable  guide, 

and  general  practitioners.    The  gist  —  The  Medical  Bulletin. 

PROGRESSIVE  MEDICINE,  see  page  32. 

PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  288 
pages,  with  18  engravings.     Cloth,  $2. 

PYE-SMITH  (PHTLD?  H.).  DISEASES  OF  THE  SKIN.  In  one 
12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2. 

QUIZ  SERD3S.     See  Student's  Quiz  Series,  page  27. 

RALFE    (CHARLES   H.).      CLINICAL      CHEMISTRY.     In    one 

12mo.  volume  of  314  pages,  with  16  engravings.     Cloth,  $1.50.     See 
Student's  Series  of  Manuals,  page  27. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND  SURGERY.  In  one 
imperial  octavo  volume  of  640  pages,  with  64  plates  and  numerous 
engravings  in  the  text.     Strongly  bound  in  leather,  $7. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. Fifth  edition,  thoroughly  revised.  In  one  12mo.  vol- 
ume of  326  pages.     Cloth,  $2. 

A  clear  and  concise  explanation  j  student  of  chemistry  or  the  practi- 
of  a  difficult  subject.  We  cordially  tioner  who  desires  to  broaden  his 
recommend  it. —  The  London  Lancet,    theoretical  knowledge  of  chemistry. 

The  book  is  equally  adapted  to  the  |  —New  Orleans  Med.  and  Surg.  Jour. 


24     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


RICHARDSON  (BENJAMIN  WARD).  PREVENTIVE  MEDI- 
CINE.    In  one  octavo  volume  of  729  pages.     Cloth,  $4 ;  leather,  $5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  New  (2d)  edition.  In  one  octavo  volume  of 
838  pages  with  473  engravings  and  8  plates.  Cloth,  $4  25,  net;  leather, 
$5.25,  net. 

A  clear,  concise,   comprehensive  satisfactory  or  valuable  single  vol- 

and  practical  presentation    of   the  ume  work  on  this  subject. — Pacific 

most  modern  surgery.     The  student  Medical  Journal. 
or  practitioner  will  not  find  a  more 

ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES,  INCLUDING  URINARY 
DEPOSITS.  Fourth,  American  from  the  fourth  London  edition.  In 
one  very  handsome  8vo.  vol.  of  609  pp.,  with  81  illus.     Cloth,  $3.50. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  handsome  octavo  volume  of  726  pages, 
with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50, 

SOHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOL- 
OGY, DESCRIPTIVE  AND  PRACTICAL.  For  the  use  of  Students. 
Fifth  edition.  In  one  handsome  octavo  volume  of  359  pages, 
with  392  illustrations.     Cloth,  $3.00,  net. 


Nowhere  else  will  the  same  very 
moderate  outlay  secure  as  thoroughly 
useful  and  interesting  an  atlas  of 
structural  anatomy. — The  American 
Journal  of  the  Medical  Sciences. 


The  most  satisfactory  elementary 
text-book  of  histology  in  the  Eng- 
lish language. — The  Boston  Med.  and 
Sur.  Jour. 


A  COURSE  OF  PRACTICAL    HISTOLOGY.    Second  edition. 

In  one  12mo.  volume  of  307  pages,  with  59  engravings.   Cloth,  $2.25. 

SCHLEIF  (WILLIAM).  MATERIA  MEDICA,  THERAPEUTICS, 
PRESCRIPTION  WRITING,  MEDICAL  LATIN,  ETC.  12mo., 
352  pages.  Cloth,  $1.50,  net;  flexible  red  leather,  $2.00,  net.  Lea's 
Series  of  Pocket  Text-books.  Edited  by  Bern  B.  Gallaudet,  M.  D. 
See  page  17. 


We  commend  the  book  for  it  con- 
tains in  a  concise,  definite,  and  as- 
similable form  the  essential  knowl- 
edge required  in  the  most  complete 


college  courses  on  Materia  Medica 
and    Therapeutics. — The    National 

Medical  Review. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     25 


SCHOFIELD  (ALFRED  T.).  ELEMENTARY  PHYSIOLOGY 
FOR  STUDENTS.  In  one  12ino.  volume  of  380  pages,  with  227 
engravings  and  2  colored  plates.     Cloth,  $2. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edi- 
tion. In  one  octavo  volume  of  268  pages,  with  13  plates,  10  of  which 
are  colored,  and  9  engravings.     Cloth,  $2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  Authoritative 
Monographs  on  Important  Clinical  Subjects,  in  12mo.  volumes  of  about 
550  pages,  well  illustrated.  The  following  volumes  are  now  ready : 
Yeo  on  Food  in  Health  and  Disease,  second  edition,  $2.50 ;  Carter 
and  Frost's  Ophthalmic  Surgery,  $2.25 ;  Marsh  on  Diseases  of  the 
Joints,  $2 ;  Owen  on  Surgical  Diseases  of  Children,  $2 ;  Pick  on 
Fractures  and  Dislocations,  $2. 
For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  STUDENT'S  MANUALS.     See  page  27. 

SIMON  (CHARLES  E.).  A  TEXT-BOOK  ON  PHYSIOLOGICAL 
CHEMISTRY.  Octavo  of  about  450  pages,  amply  illustrated.  In  press. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICRO- 
SCOPICAL AND  CHEMICAL  METHODS.  New  (3d)  edition.  In 
one  very  handsome  octavo  volume  of  563  pages,  with  138  engravings 
and  18  full-page  colored  plates.     Cloth,  $3.50,  net. 


This  book  thoroughly  deserves  its 
success.  It  is  a  very  complete,  authen- 
tic and  useful  manual  of  the  micro- 
scopical and  chemical  methods 
which  are  employed  in  diagnosis. 
Very  excellent  colored  plates  illus- 
trate this  work. — New  York  Medical 
Journal. 


In  all  respects  entirely  up  to  date. 
— Medical  Record. 

The  chapter  on  examination  or 
the  urine  is  the  most  complete  and 
advanced  that  we  know  of  in  the 
English  language. —  Canadian  Prac- 
titioner. 


SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures 
and  Laboratory  Work  for  Beginners  in  Chemistry.  A  Text-book 
specially  adapted  for  Students  of  Pharmacy  and  Medicine.  Sixth 
edition.  In  one  8vo.  volume  of  536  pages,  with  46  engravings  and  8 
plates  showing  colors  of  64  tests.  Cloth,  $3.00,  net. 
It  is  difficult  to  see  how  a  better    the  covers  of  this  book. — The  North- 

book  could  be  constructed.    No  man    western  Lancet. 

who  devotes  himself  to  the  practice       Its  statements  are  all  clear  and  its 

of  medicine  need  know  more  about    teachings    are  practical. —  Virginia 

chemistry  than  is  contained  between    Med.  Monthly. 

SLADE    (D.   D.).     DIPHTHERIA;    ITS    NATURE   AND    TREAT- 
MENT. Second  edition.  In  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 

SMITH  (EDWARD).   CONSUMPTION;  ITS  EARLY  AND  REME- 
DIABLE STAGES.     In  one  8vo.  volume  of  253  pp.     Cloth,  $2.25. 


26     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  .DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Eighth  edition,  thoroughly  revised 
and  rewritten  and  much  enlarged.  In  one  large  8vo.  volume  of  983 
pages,  with  273  engravings  and  4  full-page  plates.  Cloth,  $4.50; 
leather,  $5.50. 


A  safe  guide  for  students  and  phy- 
sicians.— The  Am.  Jour,  of  Obstetrics. 

For  years  the  leading  text-book  on 
children's  diseases  in  America. — 
Chicago  Medical  Recorder. 


The  most  complete  and  satisfac- 
tory text-book  with  which  we  are 
acquainted. — American  Gynecologi- 
cal and  Obstetrical  Journal. 


SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thor- 
oughly revised  edition.  In  one  octavo  volume  of  892  pages,  with 
1005  engravings.     Cloth,  $4  ;  leather,  $5. 


One  of  the  most  satisfactory  works 
on  modern  operative  surgery  yet 
published.     The  book  is  a  compen- 


dium for  the  modern  surgeon. — Bos- 
ton Medical  and  Surgical  Journal. 


SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMA- 
TOLOGY. In  one  handsome  octavo  volume  of  462  pages,  with  en- 
gravings and  11  full-page  plates,  5  of  which  are  in  colors.  Cloth,  $4.00. 
Every    practitioner    of   medicine        A  clear    and   lucid  summary  of 


should  possess  himself  of  a  copy  and 
study  it,  and  we  are  sure  he  will 
never  regret  it. — St.  Louis  Medical 
and  Surgical  Journal. 


what  is  known  of  climate  in  relation 
to  its  influence  upon  human  beings. 
— The  Therapeutic  Gazette. 


STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  163  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth    and 


revised  edition.      In  two  octavo  volumes,  containing    1936    pages. 
Cloth,  $10;  leather,  $12. 

STILLE  (ALFRED),  MAISCH  (JOHN  M.)  AND  CASPARI 
(CHAS.  JR.).  THE  NATIONAL  DISPENSATORY:  Containing 
the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of 
Medicines,  including  those  recognized  in  the  latest  Pharmacopoeias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  refer- 
ences to  the  French  Codex.  Fifth  edition,  revised  and  enlarged, 
including  the  new  U.  S.  Pharmacopoeia,  Seventh  Decennial  Revision. 
With  Supplement  containing  the  new  edition  of  the  National  Formu- 
lary. In  one  magnificent  imperial  octavo  volume  of  about  2025  pages, 
with  320  engravings.  Cloth,  $7.25;  leather,  $8.  With  ready  reference 
Thumb-letter  Index.    Cloth,  $7.75  ;  leather,  $8.50. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     27 


STOfSON  (LEWIS  A.).  A  MANUAL  OF  OPERATIVE  SURGERY. 
NVu  |  ith)  edition.  In  one  royal  L2mo.  volume  of  581  pages,  with  293 
engravings.     Cloth,  $3.00,  net.    Justready. 

A  useful  and  practical  -aide  for  The  book  is  worth  the  price  for  the 
all  students  and  practitioners.— Am.  j  illustrations  alone.— Ohio  Medical 
Journal  of  the  Medical  Sciences.         ;  Journal. 

STIMSON  (LEWIS  A.).      A  TREATISE  ON  FRACTURES    AND 

DISLOCATIONS.  New  (3d)  edition.  In  one  handsome  octavo  vol- 
ume of  842  pages,  with  336  engravings  and  32  plates.  Cloth,  $5.00, 
net;  leather,  $6.00,  net;  half  Morocco,  $6.50,  net. 

Preeminently   the    authoritative  |  pensable  to  the  student  and  the  prac- 

text-book  upon  the   subject.      The    titioner  alike.— 77,e  Medical  Age 

vast  experience  of  the  author  srives        <ti^        i    •    +i,    i  •     J? 

to  his  conclusions  an  unimpeachable    lis        I  f  ifr^  Tz^^ 
value.     Thp  wni-t  ?D  «w£,Mi„  :i     nsn  to-day.— M.  Louts  Medical  and 


value.     The   work  is  profusely   il- 
lustrated.    It  will  be   found  indis- 


Surgical  Journal. 


STUDENT'S  QUIZ  SERIES.  Thirteen  volumes,  convenient,  author- 
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of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics;  12.  Gynecology; 
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Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at 
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STUDENT'S  SERIES  OF  MANUALS.  12mos.  of  from  300-540 
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Clarke  and  Lockwood's  Dissector's  Manual,  $1.50. 
For  separate  notices,  see  under  various  author's  names. 

STURGES  fOCTAVTUS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  JOHN  BLAND).  SURGICAL  DISEASES  OF  THE 
OVARIES  AND  FALLOPIAN  TUBES.  Including  Abdominal 
Pregnancy.  In  one  12mo.  volume  of  513  pages,  with  119  engravings 
and  5  colored  plates.     Cloth,  $3. 

TAIT  (LAWSON).  DISEASES  OF  WOMEN  AND  ABDOMINAL 
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28     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

TANNER  (THOMAS  HAWKES)  ON  THE  SIGNS  AND  DIS- 
EASES OF  PREGNANCY.  From  the  second  English  edition.  In 
one  octavo  volume  of  490  pages,  with  4  colored  plates  and  16  engrav- 
ings.    Cloth,  $4.25. 

TAYLOR  (ALFRED   S.).     MEDICAL   JURISPRUDENCE.     New 

American  from  the  twelfth  English  edition,  specially  revised  by  Clark 

Bell,  Esq.,  of  the  N.  Y.  Bar.     In  one  8vo.  vol.  of  831  pages,  with  54 

engrs.  and  8  full-page  plates.     Cloth,  $4.50;  leather,  $5.50 

To  the  student,  as  to  the  physician,    be  found  to  be  thorough,  authorita- 

we  would  say,  get  Taylor  first,  and    tive     and     modern. — Albany     Law 

then  add  as  means  and  inclination  :  Journal. 

enable  you.— American  Practitioner  ]      probably  the  best  work  on   the 
and  Neivs.  subject  written  in  the  English  Ian- 

It  is  the  authority  accepted  as  guage.  The  work  has  been  thor- 
final  by  the  courts  of  all  English-  oughly  revised  and  is  up  to  date. — 
speaking  countries.     The  work  will  I  Pacific  Medical  Journal. 

ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDI- 
CAL JURISPRUDENCE.  Third  American  from  the  third  London 
edition.  In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5.50 ;  leather,  $6.50. 

TAYLOR  (ROBERT  W.).  GENITO-URINARY  AND  VENEREAL 

DISEASES    AND    SYPHILIS.     New    (2d)  edition.     In  one  very 
handsome  octavo  volume  of  720  pages,  with  130  engravings  and  27 
colored  plates.     Cloth,  $5.00,  Net;  leather,  $6.00,  Net. 
By  long  odds  the  best  work  on  [      It  is  a  veritable  storehouse  of  our 

venereal  diseases. — Louisville  Medi-    knowledge  of  the  venereal  diseases. 

cal  Monthly.  It  is  commended  as   a  conservative, 

The  clearest,  most  unbiased  and  i  practical,    full    exposition     of  the 

ably  presented  treatise  as  yet  pub-    greatest    value.—  Chicago    Clinical 

lished    on    this  vast   subject. — The    Review. 

Medical  News. 

TAYLOR  (ROBERT  W.).     A  PRACTICAL  TREATISE  ON  SEX- 
UAL   DISORDERS  IN  THE  MALE  AND    FEMALE.     New  (2d) 
edition.     In  one  8vo.  volume  of  434  pages,  with  91  engravings  and 
13  colored  plates.     Cloth,  $3.00,  net. 
The  author  has  presented  to  the    followed,  will  be  of  unlimited  value 

profession  the  ablest  and  most  scien-    to    both   physician    and   patient. — 

tific  work  as  yet  published  on  sexual    Medical  News. 

disorders,  and  one  wThich,  if  carefully  I 

A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 


Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  x  18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  fine  engravings  and  425 
pages  of  text.  Complete  work  now  ready.  Price  per  part,  sewed  in 
heavy  embossed  paper,  $2.50.  Bound  in  one  volume,  half  Russia, 
$27  ;  half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Address 
the  publishers.     Specimen  plates  by  mail  on  receipt  of  ten  cents. 

TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for 
the  use  of  Senior  Students  and  others.  In  one  large  12mo.  volume  of 
802  pages.    Cloth,  $3.75. 


Lea  Brothers  A  Co.,  Philadelphia  and  New  York. 


THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  F  ^      appap 
TICAL  TREATISE  ON  THE  DISEASES OF WOMEN  **££ 
edition,   thoroughly  revised   by   Paul  F.   Muxde,   M    D    '  In  one 

cioih^;tatr$rvo  volurae  of  824pages' ^  347  -As 

snbtetl?  ]ZCt  Fal  r1" iatT  °n  the        This  work>  which  has  already  go* 
vill  h    n    P       °^18h  i  lan^Se.    through  five  large  editions,  anVl  "has 
It  will  be  of  especial   value   to   the    been   translated   into   Frenoh    f£r 

s^hlLr'aTheillnr,ta:tWellaSt°the  man'   Spanish^nTltalTa^^^he 

EfStorv    M^nfS.°DSare  V6ry  Tst  Practi<*l  and  at  the  sarne  time 

sat  factory     Many  of  them  are  new  the  most  complete  treatise  unon  the 

and  are  particularly  clear  and  attrac-  subject,-^/  Archhel  of  fCJ«/ 

tive.-Boston  Med.  and  Sur.  Jour.  ogy\  Obstetrics  ZTpeVL^s^ 

THSmE(\G^A?,<    \  ™XT-BOOK  OF  PRACTICAL 

S     volume  of ■  ?m9entS  '^  .^actitioners-     ^  one  handsome 

Z  -Whe     ^  0 i, Vif-&  Wlth  79    e*gra™gs.     Cloth,  $5.00, 
race,  leatner,  Sb.OO,  net;  half  Morocco,  86.50,  rarf. 

tlon.    In  one  octavo  vol.  of  203  pp.,  with  25  engraving"    CMhf&x. 

engravKndlrT    ^^^Je^^kge^l? 

engravings  and  3  lithographic  plates.     Cloth,  $3.50. 

THOMSON  (JOHN).     DISE4SFSOF   PTTTT  tydttxt       t 

oetavovolLeofS.oOp^wftfoomus'rao'th^o  J?  "  "•"" 
,'eeIt"kb^a<imif^%WOrk  the  sub"    encroach  npon  any  existing  work 

Tm«DDS^EpTO?H)-  HME?ICAL  TREATMENT  OF  DISEASES 
U.O0,  net ,MPT0MS-     Handsome  octavo  volume  of  627  pages.     Cloth, 

sents  a  great  number  of  well-seleSed       !«  „^"  JoU"Wl  °}  3M'- 
formulas  of  every  day  use.  Certainly,  aurgery. 

T°  t5i?a,ottIeTi)?sEf^?y,t    clinical  LECTURES  ON  CER- 

IAIN  ACLTE  DISEASES.     In  one  8vo.  vol.  of  320  pp.,  cloth,  $2.50. 
TREVES    (FREDERICK).      OPER4TIVF    qnRCPPV       r      . 
8vo.  vols,  containing  15.50  pp.,  wfth  Si     aSt^fXtt,  $U° 

Fnifl™  OF  SURGERY.    In   Contributions  by  Twenty-five 

SlS8"?'  In  lT0  lar«e  octa™  ™!umes.  Vol.  1,  UTS  pa'es 
with  463  engravings  and  2  colored  plates.  Vol  II  1120  naies  with' 
487  engravtngs  and  2  colored  plates.    Complete  work,  clS,  $16  00 


30     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


TREVES   (FREDERICK).      SURGICAL   APPLIED    ANATOMY. 

New  edition.     In  one  12mo.  volume  of  600  pages,  with  61  engravings. 
Shortly.    See  Student's  Series  of  Manuals,  page  27. 

TUTTLE  (GEORGE  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  CHILDREN.  In  one  handsome  12mo.  volume  of  374  pages, 
with  5  plates.  Cloth,  $1.50,  net ;  flexible  red  leather,  $2.00,  net.' Lea's 
Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet,  M.  D. 
See  p.  17. 


It  is  a  good  work — the  author  hav- 
ing condensed  most  of  the  leading 
points  in  connection  with  diseases 


of  infancy  and  childhood  into  short 
and  readable  chapters. —  Virginia 
Medical  Semi- Monthly . 


VATJGHAN    (VICTOR    C.)    AND    NOVY    (FREDERICK    G.). 

PTOMAINS,     LEUCOMAINS,    TOXINS    AND    ANTITOXINS, 

or  the  Chemical  Factors  in  the  Causation  of  Disease.  New  (4th)  edition. 
In  one  12mo.  volume  of  about  650  pages.    Shortly. 


The  present  edition  has  been  not 
only  thoroughly  revised  throughout 
but  also  greatly  enlarged,  ample 
consideration  being  given  to  the  new 
subjects  of  toxins  and  antitoxins. — 
Tri-State  Medical  Journal. 


The  work  has  been  brought  down 
to  date,  and  will  be  found  entirely 
satisfactory. — Journal  of  the  Ameri- 
can Medical  Association. 

The  most  exhaustive  and  most  re- 
cent presentation  of  the  subject. — 
American  Jour,  of  the  Med.  Sciences. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1902. 
Four  styles :  Weekly  (dated  for  30  patients);  Monthly  (undated  for 
120  patients  per  month) ;  Perpetual  (undated  for  30  patients  each 
week);  and  Perpetual  (undated  for  60  patients  each  week).  The  60- 
patient  book  consists  of  256  pages  of  assorted  blanks.  The  first  three 
styles  contain  32  pages  of  important  data,  thoroughly  revised,  and 
160  pages  of  assorted  blanks.  Each  in  one  volume,  price,  $1.25. 
With  thumb-letter  index  for  quick  use,  25  cents  extra.  Special  rates 
to  advance-paying  subscribers  to  The  Medical  News  or  The 
American  Journal  op  the  Medical  Sciences,  or  both.  See  p.  32. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  by  H.  Hartshorne,  M.  D. 
In  two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.  Cloth,  $9 ;  leather,  $11. 

WEST  (CHARL.ES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.     Cloth,  $3.75  ;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE   NERVOUS  SYSTEM  IN 

CHILDHOOD.     In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAG- 
ING. New  (4th)  edition.  In  one  12mo.  volume  of  594  pages,  with 
502  engravings,  many  of  which  are  photographic.      $3.00,  net. 


The  part  devoted  to  bandaging  is 
perhaps  the  best  exposition  of  the 
subject  in  the  English  language.  It 
can  be  highly  commended  to  the 
student,  the  practitioner  and  the 
specialist. — The  Chicago  Medical 
Recorder. 


Well  written,  conveniently  ar- 
ranged and  amply  illustrated.  It 
covers  the  field  so  fully  as  to  render 
it  a  valuable  text-book,  as  well  as  a 
work  of  ready  reference  for  sur- 
geons.— North    Amer.  Practitioner. 


Lka  Brothers  &  Co.,  Philadelphia  and  New  York.      31 


WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR 
THERAPEUTIC  INDEX.  Including  Medical  and  Surgical  Thera- 
peutics.    In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WHITMAN'S  (ROYAL).  ORTHOPEDIC  SURGERY.  One  octavo 
volume  of  642  pages,  with  447  illustrations.     Cloth,  $5.50,  net. 

WILLIAMS  (DAWSOX).  THE  MEDICAL  DISEASES  OF  CHIL- 
DREN. New  (2d)  edition.  Specially  revised  for  America  by  F.  S. 
Churchill,  A.M.,  M.D.  In  one  octavo  volume  of  53S  pages,  with 
52  illustrations,  and  2  plates.     Cloth,  $3.50,  net. 

The  descriptions  of  symptoms  are  diagnoses,  prognosis,  complications, 

full,  and  the  treatment  recommended  and  treatment.     The  work  is  up  to 

will  meet  general  approval.    Under  date  in  everv  sense.— The  Charlotte 

each  disease  are  given  the  symptoms,  Medical  Journal. 

WILSON  (ERASMUS).    A    SYSTEM    OF    HUMAN    ANATOMY. 

A  new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  616  pages.  Cloth,  $4 ; 
leather,  $5. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
Translated  by  James  R.  Chadwick,  A.  M.,  M.  D.  With  additions 
by  the  Author.    In  one  octavo  volume  of  484  pages.     Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  eighth  German  edition,  by  Ira  Remsex,  M.  D.  In  one 
12mo.  volume  of  550  pages.     Cloth,  $3. 

YEO  (I.  BURNEY).     FOOD   IN  HEALTH  AND   DISEASE.     Sec- 
ond edition.     In  one  12mo.  volume  of  592  pages,  with  4  engravings. 
Cloth,  $2.50.    See  Series  of  Clinical  Manuals,  page  26. 
We  doubt  whether  any  book  on  [  work   of  Dr.   Yeo's.     The  value  of 


dietetics  has  been  of  greater  or  more 
widespread  usefulness  than  has  this 
much-quoted     and    much-consulted 


the  work  is  not  to  be  overestimated. 
— New  York  Medical  Journal. 


YOUNG  (JAMES  K.).     ORTHOPEDIC  SURGERY.     In    one    8vo. 
volume  of  475  pages,  with  286  illustrations.     Cloth,  $4;  leather,  $5. 

In  studying  the  different  chapters,  surgical  specialty  and  everv  pa^e 

one  is  impressed  with  the  thorough-  abounds    with    evidences    of  prac- 

ness  of  the  work.    The  illustrations  ticalitv.     It  is  the  clearest  and  most 

are  numerous— the  book  thoroughlv  modern  work  upon  this  growing  de- 

practical— Medical  Neios.  partment  of  surgerv.— The  Chicago 

It  is  a  thorough,  a  very  compre-  Clinical  Review.' 
hensive  work  upon  this  legitimate 


PERIODICALS. 


PROGRESSIVE  MEDICINE. 

A  Quarterly  Digest  of  New  Methods,  Discoveries,  and  Improvements 
in  the  Medical  and  Surgical  Sciences  by  Eminent  Authorities.  Edited  by 
Dr.  Hobart  Amory  Hare.  In  four  abundantly  illustrated,  cloth  bound, 
octavo  volumes,  of  400-500  pages  each,  issued  quarterly,  commencing 
March  1st,  1899.     Per  annum  (4  volumes),  $10.00  delivered. 


THE  MEDICAL.  NEWS. 

Weekly,  $1.00  per  Annum. 

Each  number  contains  40  quarto  pages,  abundantly  illustrated, 
crisp,  fresh  weekly  professional  newspaper. 


THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 
Monthly,  $4.00  Per  Annum. 

Each  issue  contains  128  octavo  pages,  fully  illustrated.    The  most 
advanced  and  enterprising  American  exponent  of  scientific  medicine. 


THE  MEDICAL  NEWS  VISITING  LIST. 

Four  styles,  Weekly  (dated  for  30  patients) ;  Monthly  (undated,  for 
120  patients  per  month) ;  Perpetual  (undated,  for  30  patients  weekly  per 
year) ;  and  Perpetual  (undated,  for  60  patients  per  year).  Each  style  in 
one  wallet-shaped  book,  leather  bound,  with  pocket,  pencil  and  rubber. 
Price,  each,  $1.25.    Thumb-letter  index,  25  cents  extra. 


THE  MEDICAL  NEWS  POCKET  FORMULARY. 

New  (3d)  Edition. 

Containing  over  1700  prescriptions  representing  the  latest  and  most  ap- 
proved methods  of  administering  remedial  agents.  Strongly  bound  in 
leather  ;  with  pocket  and  pencil.     Price,  $1.50,  net. 


COMBINATION    RATES: 


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*  Medical  Science",      ....  «   4.00  ■>     <t7P-n) 

z     Medical  News 4.00/   *  ' ,t>U  I  $15.00 

<     Progressive  Medicine  ....  10.00  J 

gj     Medical  News  Visiting  List         .        .        .        1.25 

°-     Medical  News  Formulary  .        .        .        1.50  net, 

In  all  S30.75  for  $16.00 

First  four  above  publications  in  combination        .        .        $15.75 

All  above  publications  in  combination    ....  16.00 

Otlier  Combinations  will  be  quoted  on  request. 

Full  Circulars  and  Specimens  free. 


LEA  BROTHERS  &  CO.,  Publishers, 

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